Provider Demographics
NPI:1477045839
Name:WHITE, BRANDON (LLMSW)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46941 CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-3203
Mailing Address - Country:US
Mailing Address - Phone:586-291-1833
Mailing Address - Fax:
Practice Address - Street 1:30101 HOOVER RD STE 1
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-6572
Practice Address - Country:US
Practice Address - Phone:586-558-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-01
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801102509104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker