Healthcare Provider Details

I. General information

NPI: 1033556709
Provider Name (Legal Business Name): MARGARET WHITESIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 06/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 S WILLIAMSON BLVD STE 774
PORT ORANGE FL
32128-8311
US

IV. Provider business mailing address

700 W PINE ST
WYTHEVILLE VA
24382-1844
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-7711
  • Fax: 866-426-2811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202006184
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: