Provider Demographics
NPI:1669832028
Name:WHITE, MUNDRAE DALLAS (LCADC)
Entity Type:Individual
Prefix:
First Name:MUNDRAE
Middle Name:DALLAS
Last Name:WHITE
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3218 MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-4561
Mailing Address - Country:US
Mailing Address - Phone:410-725-8611
Mailing Address - Fax:
Practice Address - Street 1:3218 MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-4561
Practice Address - Country:US
Practice Address - Phone:410-725-8611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLCA2225101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)