Provider Demographics
NPI:1821106725
Name:WHITE, BRIAN (LCSW)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10710 OLD HIGHWAY 64
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:TN
Mailing Address - Zip Code:38008-3587
Mailing Address - Country:US
Mailing Address - Phone:731-658-6113
Mailing Address - Fax:731-658-1597
Practice Address - Street 1:259 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DECATURVILLE
Practice Address - State:TN
Practice Address - Zip Code:38329-8033
Practice Address - Country:US
Practice Address - Phone:731-852-3112
Practice Address - Fax:731-852-3222
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW 38641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4052001OtherBCBS PROVIDER NUMBER
TN3925929Medicaid
TN3925929Medicaid