Healthcare Provider Details

I. General information

NPI: 1285840058
Provider Name (Legal Business Name): TERRI DALE WHITMORE P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 ALLUMBAUGH ST
BOISE ID
83704-8700
US

IV. Provider business mailing address

2964 W MIRMONTE ST
MERIDIAN ID
83642-2680
US

V. Phone/Fax

Practice location:
  • Phone: 208-854-8502
  • Fax:
Mailing address:
  • Phone: 208-895-0187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA-360
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: