Provider Demographics
NPI:1922472158
Name:WHITLEY, MICHAEL SHAWN JR (ATC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SHAWN
Last Name:WHITLEY
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5309 COMMONWEALTH CENTRE PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-2633
Mailing Address - Country:US
Mailing Address - Phone:804-545-7560
Mailing Address - Fax:
Practice Address - Street 1:5309 COMMONWEALTH CENTRE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-2633
Practice Address - Country:US
Practice Address - Phone:804-545-7560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-27
Last Update Date:2015-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260022072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer