Provider Demographics
NPI:1235683004
Name:WHITE, THERESA (MA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:FUNDERWHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2130 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3834
Mailing Address - Country:US
Mailing Address - Phone:970-252-3200
Mailing Address - Fax:
Practice Address - Street 1:2130 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3834
Practice Address - Country:US
Practice Address - Phone:970-252-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012078101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health