=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417541228
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAX WESTHOVEN DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2021
-----------------------------------------------------
Last Update Date | 05/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 REFUGEE RD
-----------------------------------------------------
City | PICKERINGTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43147-9653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-966-7556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 HALCYON DR
-----------------------------------------------------
City | ETNA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43062-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-966-7556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | LPT-31372
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT020531
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------