Provider Demographics
NPI:1376077305
Name:WHITE, ANGELA ANN (MA, MED, RMHCI)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA, MED, RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3670 KIRKPATRICK CIR UNIT 5
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-0208
Mailing Address - Country:US
Mailing Address - Phone:412-999-2884
Mailing Address - Fax:
Practice Address - Street 1:3670 KIRKPATRICK CIR UNIT 5
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-0208
Practice Address - Country:US
Practice Address - Phone:412-999-2884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLBACB384055106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020993800Medicaid