Provider Demographics
NPI:1659042240
Name:WHITE, MICHELLE (RBT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 SOCCER PARK RD
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2564
Mailing Address - Country:US
Mailing Address - Phone:314-793-6087
Mailing Address - Fax:314-845-3901
Practice Address - Street 1:14 SOCCER PARK RD
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2564
Practice Address - Country:US
Practice Address - Phone:314-793-6087
Practice Address - Fax:314-845-3901
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORBT21178397106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician