Provider Demographics
NPI:1720645211
Name:WHITE, MICHAEL ALLEN (MSPC, LAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALLEN
Last Name:WHITE
Suffix:
Gender:M
Credentials:MSPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7357 W CAMERON DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-8792
Mailing Address - Country:US
Mailing Address - Phone:623-866-9717
Mailing Address - Fax:
Practice Address - Street 1:18301 N 79TH AVE STE F168
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-6045
Practice Address - Country:US
Practice Address - Phone:602-633-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-18117101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health