Provider Demographics
NPI:1710955380
Name:WHITSON, JOSEPH HADEN (ATC)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:HADEN
Last Name:WHITSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BRADLEY UNIVERSITY
Mailing Address - Street 2:1501 W. BRADLEY AVENUE
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61625-0001
Mailing Address - Country:US
Mailing Address - Phone:309-677-2688
Mailing Address - Fax:309-677-3288
Practice Address - Street 1:ILLINOIS STATE UNIVERSITY
Practice Address - Street 2:CAMPUS BOX 7160
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61790-0001
Practice Address - Country:US
Practice Address - Phone:309-438-3282
Practice Address - Fax:309-438-3603
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-0021502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL096-002150OtherSTATE LICENSE