Provider Demographics
NPI:1700154432
Name:WHITE, JOHN BRIAN (OT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRIAN
Last Name:WHITE
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHWEST HARBOR
Mailing Address - State:ME
Mailing Address - Zip Code:04679-4240
Mailing Address - Country:US
Mailing Address - Phone:336-541-2867
Mailing Address - Fax:
Practice Address - Street 1:204 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHWEST HARBOR
Practice Address - State:ME
Practice Address - Zip Code:04679-4240
Practice Address - Country:US
Practice Address - Phone:336-541-2867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6748172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker