Provider Demographics
NPI:1205558012
Name:WHITE, TERRENCE LA'DELL
Entity type:Individual
Prefix:MR
First Name:TERRENCE
Middle Name:LA'DELL
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 1:1222 OLD FANNIN RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-8795
Mailing Address - Country:US
Mailing Address - Phone:601-706-9525
Mailing Address - Fax:
Practice Address - Street 1:1222 OLD FANNIN RD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-8795
Practice Address - Country:US
Practice Address - Phone:601-706-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS174H00000X, 171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No174H00000XOther Service ProvidersHealth Educator