MEDICARE: GWEN WHITEHOUSE

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	225100000X	Physical Therapist	1176120	TX

General Provider Information

NPI Number	:	1699172635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWEN WHITEHOUSE

Provider Business Mailing Address
First Line	:	2100 WEST LOOP S STE 1525
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77027-3508
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 WEST LOOP S STE 1525
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77027-3508
Country	:	US
Telephone Number	:	713-965-9998
Fax Number	:

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

Provider Enumeration Date	:	11/19/2014
Last Update Date	:	11/19/2014

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Directions to “ GWEN WHITEHOUSE ” Practice Location

Language	Start Address	Practice Location

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