Basic Information
Provider Information
NPI: 1033556709
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WHITESIDE
FirstName: MARGARET
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 700 W PINE ST
Address2:  
City: WYTHEVILLE
State: VA
PostalCode: 243821844
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 5535 S WILLIAMSON BLVD
Address2: STE 774
City: PORT ORANGE
State: FL
PostalCode: 321288311
CountryCode: US
TelephoneNumber: 8003307711
FaxNumber: 8664262811
Other Information
ProviderEnumerationDate: 06/04/2013
LastUpdateDate: 06/04/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X2202006184VAY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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