Provider Demographics
NPI:1619283975
Name:WHITWORTH, KALA CELESTE (DPT)
Entity type:Individual
Prefix:
First Name:KALA
Middle Name:CELESTE
Last Name:WHITWORTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 W STATE ST STE 210
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4085
Mailing Address - Country:US
Mailing Address - Phone:208-336-8433
Mailing Address - Fax:208-336-8441
Practice Address - Street 1:1520 W STATE ST STE 210
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4085
Practice Address - Country:US
Practice Address - Phone:208-336-8433
Practice Address - Fax:208-336-8441
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619283975OtherNPI
ID1619283975-000Medicaid
ID16529401Medicare PIN