Provider Demographics
NPI:1598147704
Name:WHITE, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:WHITE
Suffix:
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 1:1213 OPEUSHAW CT
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587
Mailing Address - Country:US
Mailing Address - Phone:252-767-1011
Mailing Address - Fax:
Practice Address - Street 1:1213 OPEUSHAW CT
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7938
Practice Address - Country:US
Practice Address - Phone:252-767-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0097301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical