Provider Demographics
NPI:1750506945
Name:SUSAN WHITE
Entity Type:Organization
Organization Name:SUSAN WHITE
Other - Org Name:EAGLE RECOVERY SERVICES & CONSULTATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, CADCIII
Authorized Official - Phone:913-837-4919
Mailing Address - Street 1:5 S PEORIA ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LOUISBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66053-4084
Mailing Address - Country:US
Mailing Address - Phone:913-837-4919
Mailing Address - Fax:913-837-4923
Practice Address - Street 1:5 S PEORIA ST
Practice Address - Street 2:SUITE 206
Practice Address - City:LOUISBURG
Practice Address - State:KS
Practice Address - Zip Code:66053-4084
Practice Address - Country:US
Practice Address - Phone:913-837-4919
Practice Address - Fax:913-837-4923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-15
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS584101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200305900AMedicaid