Provider Demographics
NPI:1790027258
Name:WHITE, MALYN TARA (MSW, LICSWA)
Entity Type:Individual
Prefix:
First Name:MALYN
Middle Name:TARA
Last Name:WHITE
Suffix:
Gender:F
Credentials:MSW, LICSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 NW 191ST ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-3015
Mailing Address - Country:US
Mailing Address - Phone:206-437-8118
Mailing Address - Fax:
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:BOX: 359760
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-744-4028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASC603350791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical