1962823153 NPI number — MR. BLAKE WHATLEY DPT, ATC/L, M.ED

Table of content: MR. BLAKE WHATLEY DPT, ATC/L, M.ED (NPI 1962823153)

General
Organization/Personal Information
Provider's Other Name Information
NPI Number Information
Provider's Business Mailing Address
Provider's Practice Location Mailing Address
Additional Information
Authorized Official
Provider Taxonomy Codes
Other Provider's Identifiers (legacy, non-NPI)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962823153 NPI number — MR. BLAKE WHATLEY DPT, ATC/L, M.ED

Organization/Personal Information

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:
WHATLEY

Provider First Name:
BLAKE

Provider Middle Name:

Provider Name Prefix Text:
MR.

Provider Name Suffix Text:

Provider Credential Text:
DPT, ATC/L, M.ED

Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962823153

Entity Type Code:
Individual

Replacement NPI:

Last Update Date:
08/26/2014

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 WHATLEY RD

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:
MERIGOLD

Provider Business Mailing Address State Name:
MS

Provider Business Mailing Address Postal Code:
38759-9616

Provider Business Mailing Address Country Code:
US

Provider Business Mailing Address Telephone Number:
662-719-5223

Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 HIGHWAY 12 W STE D

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:
STARKVILLE

Provider Business Practice Location Address State Name:
MS

Provider Business Practice Location Address Postal Code:
39759-3697

Provider Business Practice Location Address Country Code:
US

Provider Business Practice Location Address Telephone Number:
228-388-5714

Provider Business Practice Location Address Fax Number:
228-388-0017

Provider Enumeration Date:
12/15/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

Provider Taxonomy Codes

Taxonomy code: 2255A2300X , with the licence number: AT0488 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Taxonomy code: 225100000X , with the licence number: PT5634 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .