Provider Demographics
NPI:1962823153
Name:WHATLEY, BLAKE (DPT, ATC/L, MED)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:
Last Name:WHATLEY
Suffix:
Gender:M
Credentials:DPT, ATC/L, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WHATLEY RD
Mailing Address - Street 2:
Mailing Address - City:MERIGOLD
Mailing Address - State:MS
Mailing Address - Zip Code:38759-9616
Mailing Address - Country:US
Mailing Address - Phone:662-719-5223
Mailing Address - Fax:
Practice Address - Street 1:450 HIGHWAY 12 W STE D
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3697
Practice Address - Country:US
Practice Address - Phone:228-388-5714
Practice Address - Fax:228-388-0017
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-15
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT04882255A2300X
MSPT5634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer