Provider Demographics
NPI:1689601247
Name:WHITE, TIMOTHY MICHAEL (ATC, LAT, CSCS)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:WHITE
Suffix:
Gender:M
Credentials:ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 HENSLOW AVE N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5015
Mailing Address - Country:US
Mailing Address - Phone:651-206-4972
Mailing Address - Fax:
Practice Address - Street 1:2419 HENSLOW AVE N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5015
Practice Address - Country:US
Practice Address - Phone:651-206-4972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer