Provider Demographics
NPI:1831674910
Name:WHITAKER, ETHAN M
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:M
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 RAND RD STE 300
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-2359
Mailing Address - Country:US
Mailing Address - Phone:847-324-3976
Mailing Address - Fax:847-929-1154
Practice Address - Street 1:28156 W NORTHPOINTE PKWY STE 125
Practice Address - Street 2:
Practice Address - City:LAKE BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-2346
Practice Address - Country:US
Practice Address - Phone:224-512-9800
Practice Address - Fax:224-512-9714
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant