Provider Demographics
NPI:1790831634
Name:WHITE, DENNIS K (PHD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:K
Last Name:WHITE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-2205
Mailing Address - Country:US
Mailing Address - Phone:920-746-1346
Mailing Address - Fax:920-746-1347
Practice Address - Street 1:207 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-2205
Practice Address - Country:US
Practice Address - Phone:920-746-1346
Practice Address - Fax:920-746-1347
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI709-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39016800Medicaid
WI39016800Medicaid
WI44227Medicare ID - Type Unspecified