Provider Demographics
NPI:1790202414
Name:SEPULVEDA, WHITLEY BROOK
Entity Type:Individual
Prefix:
First Name:WHITLEY
Middle Name:BROOK
Last Name:SEPULVEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 FORT GATES
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-9740
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:833 FORT GATES
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-9740
Practice Address - Country:US
Practice Address - Phone:254-722-6073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer