Provider Demographics
NPI:1255185542
Name:WHITE, TERESA KAY (LAC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:KAY
Last Name:WHITE
Suffix:
Gender:F
Credentials:LAC
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 802
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:SD
Mailing Address - Zip Code:57266-0802
Mailing Address - Country:US
Mailing Address - Phone:605-398-6337
Mailing Address - Fax:605-398-5337
Practice Address - Street 1:505 ASH ST
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:SD
Practice Address - Zip Code:57266-2115
Practice Address - Country:US
Practice Address - Phone:605-398-6337
Practice Address - Fax:605-398-5337
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD12091534101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)