Provider Demographics
NPI:1790460152
Name:WHITESIDE, THERESA MAXINE (PTA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MAXINE
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MAXINE
Other - Last Name:DUNCKEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8500 FLETCHER RD
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-8908
Mailing Address - Country:US
Mailing Address - Phone:810-701-7827
Mailing Address - Fax:
Practice Address - Street 1:8500 FLETCHER RD
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-8908
Practice Address - Country:US
Practice Address - Phone:810-701-7827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003469225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant