Provider Demographics
NPI:1962830075
Name:WHITE, SLY (BS)
Entity Type:Individual
Prefix:
First Name:SLY
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13586
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73113-1586
Mailing Address - Country:US
Mailing Address - Phone:405-627-5959
Mailing Address - Fax:405-524-5528
Practice Address - Street 1:3621 N KELLEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73111-4520
Practice Address - Country:US
Practice Address - Phone:405-524-5525
Practice Address - Fax:405-524-5528
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)