Provider Demographics
NPI:1639437395
Name:WHORTEN, GEORGE A JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:A
Last Name:WHORTEN
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35
Mailing Address - Street 2:
Mailing Address - City:GOODFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:61742-0035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:GOODFIELD
Practice Address - State:IL
Practice Address - Zip Code:61742-9618
Practice Address - Country:US
Practice Address - Phone:309-645-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160002868172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker