Provider Demographics
NPI:1952688368
Name:WHITE, MARY SUSAN (LPCC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
Last Name:WHITE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 45TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-4026
Mailing Address - Country:US
Mailing Address - Phone:612-240-5459
Mailing Address - Fax:
Practice Address - Street 1:1798 HEWITT AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1129
Practice Address - Country:US
Practice Address - Phone:612-240-5459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC00397101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional