Provider Demographics
NPI:1609631902
Name:WHITE, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13837 LANYARD WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8643
Mailing Address - Country:US
Mailing Address - Phone:815-988-1504
Mailing Address - Fax:
Practice Address - Street 1:13837 LANYARD WAY
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-8643
Practice Address - Country:US
Practice Address - Phone:815-988-1504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-15
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1944644103TS0200X
WA606316H103TS0200X
OR567799103TS0200X
FL1092984103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool