Provider Demographics
NPI:1265293781
Name:WHITE, MYA (LLMSW)
Entity type:Individual
Prefix:
First Name:MYA
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 N CLARENDON ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49006-3072
Mailing Address - Country:US
Mailing Address - Phone:513-485-5646
Mailing Address - Fax:
Practice Address - Street 1:445 N CLARENDON ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-3072
Practice Address - Country:US
Practice Address - Phone:513-485-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6851117031104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker