Provider Demographics
NPI:1346814258
Name:WHITE, BROOKLYN
Entity Type:Individual
Prefix:
First Name:BROOKLYN
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 1:38035 POST OFFICE RD APT 22A
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4292
Mailing Address - Country:US
Mailing Address - Phone:205-983-2402
Mailing Address - Fax:
Practice Address - Street 1:15053 E LAKEFRONT DR
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-7077
Practice Address - Country:US
Practice Address - Phone:225-202-3323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator