Healthcare Provider Details

I. General information

NPI: 1710955380
Provider Name (Legal Business Name): JOSEPH HADEN WHITSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 05/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ILLINOIS STATE UNIVERSITY CAMPUS BOX 7160
NORMAL IL
61790-0001
US

IV. Provider business mailing address

BRADLEY UNIVERSITY 1501 W. BRADLEY AVENUE
PEORIA IL
61625-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-3282
  • Fax: 309-438-3603
Mailing address:
  • Phone: 309-677-2688
  • Fax: 309-677-3288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096-002150
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: