Provider Demographics
NPI:1891557203
Name:WHITE, COREY GLEN
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:GLEN
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-2022
Mailing Address - Country:US
Mailing Address - Phone:318-716-1369
Mailing Address - Fax:318-675-0120
Practice Address - Street 1:404 HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-2022
Practice Address - Country:US
Practice Address - Phone:318-716-1369
Practice Address - Fax:318-675-0120
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)