Provider Demographics
NPI:1013373562
Name:WHITE, ALICIA JACLYN (BCBA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:JACLYN
Last Name:WHITE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:ALICIA
Other - Middle Name:JACLYN
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 DEPAUW BOULEVARD
Mailing Address - Street 2:SUITE 3070
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-6135
Mailing Address - Country:US
Mailing Address - Phone:855-324-0885
Mailing Address - Fax:765-450-6664
Practice Address - Street 1:17390 DUGDALE DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1512
Practice Address - Country:US
Practice Address - Phone:574-400-2169
Practice Address - Fax:765-450-6664
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-15-21144103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300009394Medicaid
1-15-21144OtherBCBA CERTIFICATE