Provider Demographics
NPI:1932641404
Name:WHITSELL, MAX
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:WHITSELL
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:SOUTHEASTERN LOUISIANA UNIVERSITY ATHLETICS
Mailing Address - Street 2:SLU 10309
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70402-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 GALLOWAY DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70402-0001
Practice Address - Country:US
Practice Address - Phone:985-549-5401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.2003842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer