Provider Demographics
NPI:1528057536
Name:WHALEN, VINCENT M (PT, MS, OCS, NCS)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:M
Last Name:WHALEN
Suffix:
Gender:M
Credentials:PT, MS, OCS, NCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 SMOKERISE DR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-8702
Mailing Address - Country:US
Mailing Address - Phone:330-335-4200
Mailing Address - Fax:330-335-7131
Practice Address - Street 1:145 SMOKERISE DR
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-8702
Practice Address - Country:US
Practice Address - Phone:330-335-4200
Practice Address - Fax:330-335-7131
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4688225100000X
OHPT046882251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0968529Medicaid
OH0968529Medicaid