Provider Demographics
NPI:1649619537
Name:WHITE, CONSTANCE RENAE (MA)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:RENAE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:RENAE
Other - Last Name:BURDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2707 3 OAKS RD UNIT 932
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-3525
Mailing Address - Country:US
Mailing Address - Phone:224-432-6419
Mailing Address - Fax:
Practice Address - Street 1:500 COVENTRY LN STE 130
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7578
Practice Address - Country:US
Practice Address - Phone:815-889-0582
Practice Address - Fax:815-205-4083
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor