Provider Demographics
NPI:1295806339
Name:WHITE, JUDITH A (MA)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:A
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:WHITE-O'BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 19696
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49019-0696
Mailing Address - Country:US
Mailing Address - Phone:269-353-7607
Mailing Address - Fax:269-888-2260
Practice Address - Street 1:1011 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008
Practice Address - Country:US
Practice Address - Phone:269-353-7607
Practice Address - Fax:269-888-2260
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401005003101Y00000X, 101YM0800X
MI6301008661103T00000X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2029602OtherCIGNA BEHAVIORAL HEALTH
MI0895250OtherBCBS OF MICHIGAN
MI0C91775OtherBCBS OF MICHIGAN
MI127-089OtherVALUE OPTIONS