Provider Demographics
NPI:1417063298
Name:WHITE, THERESA (LCPC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:MILES CITY
Mailing Address - State:MT
Mailing Address - Zip Code:59301-5000
Mailing Address - Country:US
Mailing Address - Phone:406-234-1687
Mailing Address - Fax:406-234-0235
Practice Address - Street 1:2508 WILSON ST
Practice Address - Street 2:
Practice Address - City:MILES CITY
Practice Address - State:MT
Practice Address - Zip Code:59301-5000
Practice Address - Country:US
Practice Address - Phone:406-234-1687
Practice Address - Fax:406-234-0235
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT19347101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health