Provider Demographics
NPI:1972233757
Name:WHITE, BAX WILDER (MSW)
Entity Type:Individual
Prefix:
First Name:BAX
Middle Name:WILDER
Last Name:WHITE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8982 N EXETER AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5920
Mailing Address - Country:US
Mailing Address - Phone:503-860-3064
Mailing Address - Fax:
Practice Address - Street 1:3615 NE GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2104
Practice Address - Country:US
Practice Address - Phone:503-281-1166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical