Provider Demographics
NPI:1154072940
Name:WHITE, COLLEEN T
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:T
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11235 S MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-1420
Mailing Address - Country:US
Mailing Address - Phone:773-343-3780
Mailing Address - Fax:
Practice Address - Street 1:11235 S MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-1420
Practice Address - Country:US
Practice Address - Phone:773-343-3780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor