Provider Demographics
NPI:1316603293
Name:WHITE, VICTORIA M
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:M
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 1:20263 HOLLIE LN
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-5215
Mailing Address - Country:US
Mailing Address - Phone:985-502-4429
Mailing Address - Fax:
Practice Address - Street 1:20263 HOLLIE LN
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-5215
Practice Address - Country:US
Practice Address - Phone:225-349-7960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011518960103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst