Provider Demographics
NPI:1265601504
Name:WHITE, MARY T
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:T
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:T
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:2675 LARPENTEUR AVE E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55109-5003
Mailing Address - Country:US
Mailing Address - Phone:651-777-8181
Mailing Address - Fax:651-777-4442
Practice Address - Street 1:68 EXCHANGE ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1006
Practice Address - Country:US
Practice Address - Phone:651-222-4373
Practice Address - Fax:651-777-4442
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-20
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN042681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN610098800Medicaid