Provider Demographics
NPI:1508916438
Name:WHITE, MIA S (LPCA)
Entity Type:Individual
Prefix:MS
First Name:MIA
Middle Name:S
Last Name:WHITE
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:S
Other - Last Name:MEDLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1351 NEWTOWN PIKE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-1217
Mailing Address - Country:US
Mailing Address - Phone:859-253-1686
Mailing Address - Fax:859-254-2743
Practice Address - Street 1:322 CRAB ORCHARD ST
Practice Address - Street 2:STE 1
Practice Address - City:LANCASTER
Practice Address - State:KY
Practice Address - Zip Code:40444-1222
Practice Address - Country:US
Practice Address - Phone:859-253-1686
Practice Address - Fax:859-254-2743
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0168101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY30615058Medicaid