Provider Demographics
NPI:1033476668
Name:WHITE, TAVORRIS D (MS)
Entity Type:Individual
Prefix:MR
First Name:TAVORRIS
Middle Name:D
Last Name:WHITE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 ZEBULON RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-7606
Mailing Address - Country:US
Mailing Address - Phone:478-477-3383
Mailing Address - Fax:478-475-9492
Practice Address - Street 1:6601 ZEBULON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-7606
Practice Address - Country:US
Practice Address - Phone:478-477-3383
Practice Address - Fax:478-475-9492
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
GA009771101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171W00000XOther Service ProvidersContractor