Provider Demographics
NPI:1922498799
Name:WHITTAKER, GLINDA (LPTA, LMT)
Entity Type:Individual
Prefix:
First Name:GLINDA
Middle Name:
Last Name:WHITTAKER
Suffix:
Gender:F
Credentials:LPTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17352 MAIN ST N
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1763
Mailing Address - Country:US
Mailing Address - Phone:850-674-7639
Mailing Address - Fax:850-674-4305
Practice Address - Street 1:4230 LAFAYETTE ST STE C
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-8231
Practice Address - Country:US
Practice Address - Phone:850-526-1093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-30
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA25146225200000X
FLMA30601225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist