Provider Demographics
NPI:1679746234
Name:WHITE, MARK ALLEN (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:WHITE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-0465
Mailing Address - Country:US
Mailing Address - Phone:405-567-5542
Mailing Address - Fax:
Practice Address - Street 1:1025 MEADOWBROOK AVE
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864
Practice Address - Country:US
Practice Address - Phone:405-380-1135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-03
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3984101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health