Provider Demographics
NPI:1477032563
Name:WHITE, ANISSA (LCSW)
Entity Type:Individual
Prefix:
First Name:ANISSA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 KNIGHTS MILL DR
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31605-6582
Mailing Address - Country:US
Mailing Address - Phone:518-569-5371
Mailing Address - Fax:
Practice Address - Street 1:3316 BEMISS RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31605-7014
Practice Address - Country:US
Practice Address - Phone:229-262-7333
Practice Address - Fax:229-262-7335
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-09
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0068731041C0700X
AZLCSW-173431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW006873OtherGA BOARD OF PROFESSIONAL COUNSELORS, SOCIAL WORKERS AND MARRIAGE & FAMILY THERAP
AZLCSW-17343OtherAZ STATE BOARD OF BEHAVIORAL HEALTH EXAMINERS