Provider Demographics
NPI:1679248736
Name:WHITE, ALYSSA STORM (MS)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:STORM
Last Name:WHITE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 BERRY CREEK RD # 3F
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-3320
Mailing Address - Country:US
Mailing Address - Phone:919-610-7461
Mailing Address - Fax:
Practice Address - Street 1:4012 PARK RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-2378
Practice Address - Country:US
Practice Address - Phone:704-332-4834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16732101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health