Provider Demographics
NPI:1275265019
Name:WHITE, JUSTIN WAYNE
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:WAYNE
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 NW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-5223
Mailing Address - Country:US
Mailing Address - Phone:541-766-6835
Mailing Address - Fax:
Practice Address - Street 1:530 NW 27TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-5223
Practice Address - Country:US
Practice Address - Phone:541-766-6835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health