Basic Information
| Provider Information | |||||||||
| NPI: | 1932322096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITTAKER | ||||||||
| FirstName: | BEN | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | RPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST | ||||||||
| Address2: | PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
| FaxNumber: | 8775140903 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 DESOTO AVE. | ||||||||
| Address2: | |||||||||
| City: | WOODLAND HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187192930 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT 18603 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.