Provider Demographics
NPI:1790777357
Name:WHITE, BYRON A (PSYD)
Entity Type:Individual
Prefix:
First Name:BYRON
Middle Name:A
Last Name:WHITE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7511 NEW LAGRANGE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4859
Mailing Address - Country:US
Mailing Address - Phone:502-423-1151
Mailing Address - Fax:502-423-1748
Practice Address - Street 1:7511 NEW LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4859
Practice Address - Country:US
Practice Address - Phone:502-423-1151
Practice Address - Fax:502-423-1748
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1115103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY89011159Medicaid
KY3001408Medicare ID - Type Unspecified
KY89011159Medicaid