Provider Demographics
NPI:1639168321
Name:WHITEFORD, COLLEEN M (PT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:WHITEFORD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 E SPRINGBROOK RD
Mailing Address - Street 2:
Mailing Address - City:BROADWAY
Mailing Address - State:VA
Mailing Address - Zip Code:22815-9526
Mailing Address - Country:US
Mailing Address - Phone:540-901-9501
Mailing Address - Fax:540-828-6583
Practice Address - Street 1:171 E SPRINGBROOK RD
Practice Address - Street 2:
Practice Address - City:BROADWAY
Practice Address - State:VA
Practice Address - Zip Code:22815-9526
Practice Address - Country:US
Practice Address - Phone:540-901-9501
Practice Address - Fax:540-901-8773
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305002987174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA194034OtherANTHEM PROVIDER NUMBER
VAC05976Medicare PIN