Provider Demographics
NPI:1336500362
Name:WHITE, MELINDA
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
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 1:11883 S POULTRY DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6812
Mailing Address - Country:US
Mailing Address - Phone:801-599-5119
Mailing Address - Fax:
Practice Address - Street 1:885 W BAXTER DR
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8506
Practice Address - Country:US
Practice Address - Phone:801-599-5119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-18
Last Update Date:2019-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT379066-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical