Provider Demographics
NPI:1972794428
Name:WHITEHEAD, CRAIG MICHAEL (PT)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:MICHAEL
Last Name:WHITEHEAD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 MAIN ST
Mailing Address - Street 2:UNIT F-302
Mailing Address - City:LAKE COMO
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-3085
Mailing Address - Country:US
Mailing Address - Phone:732-556-6609
Mailing Address - Fax:
Practice Address - Street 1:1945 ROUTE 33
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4859
Practice Address - Country:US
Practice Address - Phone:732-775-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2011-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01249800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01249800OtherBOARD OF PHYSICAL THERAPY