Provider Demographics
NPI:1790257095
Name:WHITBECK, BLAKELEY MATTHEW (PTA)
Entity Type:Individual
Prefix:
First Name:BLAKELEY
Middle Name:MATTHEW
Last Name:WHITBECK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-4807
Mailing Address - Country:US
Mailing Address - Phone:580-317-7455
Mailing Address - Fax:
Practice Address - Street 1:807 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4807
Practice Address - Country:US
Practice Address - Phone:580-317-7455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2126370225200000X
OK2709225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant