Provider Demographics
NPI:1003451394
Name:WHITE, CASAUNDRA
Entity Type:Individual
Prefix:
First Name:CASAUNDRA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:706-980-4700
Mailing Address - Fax:
Practice Address - Street 1:535 RIVERSTONE PKWY STE 100
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5328
Practice Address - Country:US
Practice Address - Phone:470-531-0430
Practice Address - Fax:470-408-2550
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19-98984106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician