Provider Demographics
NPI:1073097374
Name:WHITE, GLENNISHA S (BCBA)
Entity Type:Individual
Prefix:
First Name:GLENNISHA
Middle Name:S
Last Name:WHITE
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 RICHMOND PKWY APT 115
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-5208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:180 GRAND AVE STE 225
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3769
Practice Address - Country:US
Practice Address - Phone:510-506-7910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-21-48734103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst