Provider Demographics
NPI:1881003697
Name:WHITE, KEISHA CLAUDETTE (PSYD)
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:CLAUDETTE
Last Name:WHITE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 S MYRTLE AVE # 149
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-3423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8300 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3493
Practice Address - Country:US
Practice Address - Phone:201-522-5955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X
CAPSY31617103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent