Provider Demographics
NPI:1386841153
Name:WHITE, TRACELA MICHELLE (PHD)
Entity Type:Individual
Prefix:MS
First Name:TRACELA
Middle Name:MICHELLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 E UPSAL ST
Mailing Address - Street 2:APT. 1
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2601
Mailing Address - Country:US
Mailing Address - Phone:215-548-4237
Mailing Address - Fax:
Practice Address - Street 1:34 PEACHTREE ST NW
Practice Address - Street 2:SUITE 770
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-2316
Practice Address - Country:US
Practice Address - Phone:912-557-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS0151431744R1102X
GAPSY003238103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1744R1102XOther Service ProvidersSpecialistResearch Study