Provider Demographics
NPI:1770503039
Name:WHITAKER, MICHELLE (LAT, PES)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:LAT, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 W MONROVIA AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4432
Mailing Address - Country:US
Mailing Address - Phone:414-566-4583
Mailing Address - Fax:414-566-4640
Practice Address - Street 1:N63W23075 MAIN ST
Practice Address - Street 2:
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-5303
Practice Address - Country:US
Practice Address - Phone:414-566-4583
Practice Address - Fax:414-566-4640
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI481-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer