Provider Demographics
NPI:1003279472
Name:WHITE, EDWARD (MA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 ERINDALE DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-6736
Mailing Address - Country:US
Mailing Address - Phone:719-686-4635
Mailing Address - Fax:
Practice Address - Street 1:5555 ERINDALE DR
Practice Address - Street 2:SUITE 204
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-6736
Practice Address - Country:US
Practice Address - Phone:719-686-4635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC0014070101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health