Provider Demographics
NPI:1063489862
Name:WHITE, CHARLA JEANINE
Entity Type:Individual
Prefix:DR
First Name:CHARLA
Middle Name:JEANINE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHARLA
Other - Middle Name:JEANINE
Other - Last Name:WIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:2997 STOCKHOLM WAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-4286
Mailing Address - Country:US
Mailing Address - Phone:703-680-5146
Mailing Address - Fax:
Practice Address - Street 1:9625 SURVEYOR CT
Practice Address - Street 2:SUITE 200
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4422
Practice Address - Country:US
Practice Address - Phone:703-330-9933
Practice Address - Fax:703-368-8454
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003345103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0515622Medicaid