Provider Demographics
NPI:1932427937
Name:WHITAKER, MATTHEW LYLE (MS, PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LYLE
Last Name:WHITAKER
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:7800 SW DURHAM RD
Practice Address - Street 2:SUITE 500
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7577
Practice Address - Country:US
Practice Address - Phone:503-937-0090
Practice Address - Fax:503-372-5191
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT34283225100000X
OR61612225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist