Provider Demographics
NPI:1659309508
Name:WHITE, LAURA (SA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:SA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E HENRY AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33610-4432
Mailing Address - Country:US
Mailing Address - Phone:813-239-1179
Mailing Address - Fax:813-237-3091
Practice Address - Street 1:2215 E HENRY AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33610-4432
Practice Address - Country:US
Practice Address - Phone:813-239-1179
Practice Address - Fax:813-237-3091
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 4821235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA 4821OtherSPEECH LANGUAGE PATHOLOGI
FLS1269OtherBCBS