Provider Demographics
NPI:1619229317
Name:WHITE, CLEOTIS (MSW, LCAC)
Entity Type:Individual
Prefix:MR
First Name:CLEOTIS
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:MSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 HIGHWAY AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-1662
Mailing Address - Country:US
Mailing Address - Phone:219-801-1789
Mailing Address - Fax:219-513-9506
Practice Address - Street 1:2646 HIGHWAY AVE STE 108
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322
Practice Address - Country:US
Practice Address - Phone:219-801-1789
Practice Address - Fax:219-513-9506
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000827A101YA0400X
INCII-1752101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional