Provider Demographics
NPI:1083247357
Name:WHITE, EDWARD SCOTT (LISAC)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:SCOTT
Last Name:WHITE
Suffix:
Gender:M
Credentials:LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 E BELL RD UNIT 1042
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-2973
Mailing Address - Country:US
Mailing Address - Phone:602-300-8438
Mailing Address - Fax:
Practice Address - Street 1:2150 E BELL RD UNIT 1042
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-2973
Practice Address - Country:US
Practice Address - Phone:602-300-8438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-15091101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)