Provider Demographics
NPI:1649729625
Name:WHITE, EMILY (DPT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 LEXIS CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-4814
Mailing Address - Country:US
Mailing Address - Phone:309-824-7297
Mailing Address - Fax:
Practice Address - Street 1:19 LEXIS CT
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-4814
Practice Address - Country:US
Practice Address - Phone:309-824-7297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-01
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-4534225100000X
IN05012100A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist