Provider Demographics
NPI:1881188472
Name:WHITE, TIESHA L
Entity Type:Individual
Prefix:
First Name:TIESHA
Middle Name:L
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7247 BRISA RD
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-0089
Mailing Address - Country:US
Mailing Address - Phone:682-472-2373
Mailing Address - Fax:
Practice Address - Street 1:320 WESTWAY PL
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76018-5245
Practice Address - Country:US
Practice Address - Phone:817-516-9100
Practice Address - Fax:817-516-9102
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX79906101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional