Provider Demographics
NPI:1700333499
Name:WHITE, ANGELIQUE NICHOLE
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:NICHOLE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGEL
Other - Middle Name:NICHOLE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:138 W HIGHLAND RD
Mailing Address - Street 2:SUITE 400-600
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-2168
Mailing Address - Country:US
Mailing Address - Phone:248-219-8066
Mailing Address - Fax:
Practice Address - Street 1:138 W HIGHLAND RD
Practice Address - Street 2:SUITE 400-600
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843
Practice Address - Country:US
Practice Address - Phone:248-219-8066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician