Provider Demographics
NPI:1689782195
Name:WHALEN, MARSHA LYNN (PT)
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:LYNN
Last Name:WHALEN
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 1:6565 WEST MAIN SUITE 101
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009
Mailing Address - Country:US
Mailing Address - Phone:269-372-1027
Mailing Address - Fax:269-372-2940
Practice Address - Street 1:1707 FOUNTAINVIEW DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5091
Practice Address - Country:US
Practice Address - Phone:817-752-9662
Practice Address - Fax:269-372-2940
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011990225100000X
TX1245442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1245442OtherTEXAS PHYSICAL THERAPY LICENSE
MI5501011990OtherPT LICENSE