Provider Demographics
NPI:1790012771
Name:WHITE, G ZACHARIAH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:G
Middle Name:ZACHARIAH
Last Name:WHITE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:MR
Other - First Name:GARY
Other - Middle Name:ZACHARIAH
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2375 UNIVERSITY AVE W STE 160
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-1632
Mailing Address - Country:US
Mailing Address - Phone:612-208-9739
Mailing Address - Fax:612-643-3479
Practice Address - Street 1:2375 UNIVERSITY AVE W STE 160
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1632
Practice Address - Country:US
Practice Address - Phone:612-208-9739
Practice Address - Fax:612-643-3479
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-11
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5211103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist