Provider Demographics
NPI:1821603283
Name:WHITE, MICAH JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICAH
Middle Name:JOHN
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 1:1545 ALEXANDER ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-3303
Mailing Address - Country:US
Mailing Address - Phone:616-822-9713
Mailing Address - Fax:
Practice Address - Street 1:1000 MONROE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1455
Practice Address - Country:US
Practice Address - Phone:616-259-7207
Practice Address - Fax:616-259-7261
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-12
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6351004265103T00000X
MI6301018963103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist