Provider Demographics
NPI:1851729842
Name:WHITE, GINA (MHS, OTR/L)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:MHS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5478
Mailing Address - Country:US
Mailing Address - Phone:706-496-5786
Mailing Address - Fax:
Practice Address - Street 1:817 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-3772
Practice Address - Country:US
Practice Address - Phone:706-736-1255
Practice Address - Fax:706-736-1258
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
GAOT005787225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140054AMedicaid