Provider Demographics
NPI:1629028980
Name:WHITE, MARK (MS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25094 600TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55918-8502
Mailing Address - Country:US
Mailing Address - Phone:507-259-8107
Mailing Address - Fax:507-266-0003
Practice Address - Street 1:322 ELTON HILLS DR NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-2476
Practice Address - Country:US
Practice Address - Phone:507-226-0002
Practice Address - Fax:507-226-0003
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN903106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN136742OtherUCARE
MN497S2FAOtherBLUE CROSS BLUE SHIELD