Provider Demographics
NPI:1851995575
Name:WHITE, KEANDRA (MT-BC)
Entity Type:Individual
Prefix:
First Name:KEANDRA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:KEANDRA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MT-BC
Mailing Address - Street 1:3901 TURNBURY ST
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7050
Mailing Address - Country:US
Mailing Address - Phone:813-226-7055
Mailing Address - Fax:
Practice Address - Street 1:18288 N US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-4400
Practice Address - Country:US
Practice Address - Phone:813-527-9638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLF226Medicaid