Provider Demographics
NPI:1518379650
Name:WHITE, MICHAEL JR
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WHITE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16134 COLLINSON AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3651
Mailing Address - Country:US
Mailing Address - Phone:313-585-3534
Mailing Address - Fax:
Practice Address - Street 1:3100 BROADWAY ST.
Practice Address - Street 2:SUITE 400
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2202
Practice Address - Country:US
Practice Address - Phone:586-335-2006
Practice Address - Fax:586-279-3886
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704288194363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health