Provider Demographics
NPI:1275886632
Name:WHITE, MICHELE JACQUELINE (MA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:JACQUELINE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 JOHNSON ST. N.E.
Mailing Address - Street 2:
Mailing Address - City:MPLS
Mailing Address - State:MN
Mailing Address - Zip Code:55418
Mailing Address - Country:US
Mailing Address - Phone:612-916-8819
Mailing Address - Fax:651-407-3751
Practice Address - Street 1:7580 160TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-8348
Practice Address - Country:US
Practice Address - Phone:952-898-1133
Practice Address - Fax:952-435-6797
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2017-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN2411106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health