Provider Demographics
NPI:1295886240
Name:WHITE, YVETTE THEOLA (MS, OTR L)
Entity type:Individual
Prefix:
First Name:YVETTE
Middle Name:THEOLA
Last Name:WHITE
Suffix:
Gender:F
Credentials:MS, OTR L
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 1084
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1084
Mailing Address - Country:US
Mailing Address - Phone:505-627-2570
Mailing Address - Fax:
Practice Address - Street 1:300 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4636
Practice Address - Country:US
Practice Address - Phone:505-627-2570
Practice Address - Fax:505-627-2544
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1714225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39181871Medicaid