Provider Demographics
NPI:1134481658
Name:WHITE, GRANT III (PSYD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:
Last Name:WHITE
Suffix:III
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23002 AMBER LN
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-1282
Mailing Address - Country:US
Mailing Address - Phone:708-503-9880
Mailing Address - Fax:708-679-0015
Practice Address - Street 1:222 MERCHANDISE MART PLZ
Practice Address - Street 2:SUITE 13-659 ROOM #1352
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-1103
Practice Address - Country:US
Practice Address - Phone:708-207-8074
Practice Address - Fax:708-679-0015
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-005123103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical