MEDICARE: THERESA MAXINE WHITESIDE PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	5502003469	MI

General Provider Information

NPI Number	:	1790460152
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA MAXINE WHITESIDE PTA

Provider Business Mailing Address
First Line	:	8500 FLETCHER RD
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8908
Country	:	US
Telephone Number	:	810-701-7827
Fax Number	:

Provider Business Practice Location Address
First Line	:	8500 FLETCHER RD
Second Line	:
City	:	GRAND BLANC
State	:	MI
Zip	:	48439-8908
Country	:	US
Telephone Number	:	810-701-7827
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2023
Last Update Date	:	06/21/2023

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