Provider Demographics
NPI:1134276686
Name:WHITE, BENJAMIN PARKER (MA , PSYD)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:PARKER
Last Name:WHITE
Suffix:
Gender:M
Credentials:MA , PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BASS RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-7301
Mailing Address - Country:US
Mailing Address - Phone:478-475-4608
Mailing Address - Fax:478-476-8397
Practice Address - Street 1:500 BASS RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-7301
Practice Address - Country:US
Practice Address - Phone:478-475-4608
Practice Address - Fax:478-476-8397
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC000934101YP2500X
GAMFT000384106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist