Provider Demographics
NPI:1801927991
Name:WHITE, RENEE L (LCSW)
Entity type:Individual
Prefix:MS
First Name:RENEE
Middle Name:L
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 NORTHERN AVE
Mailing Address - Street 2:#3
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-2481
Mailing Address - Country:US
Mailing Address - Phone:928-757-8589
Mailing Address - Fax:928-757-0744
Practice Address - Street 1:1565 NORTHERN AVE
Practice Address - Street 2:#3
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2481
Practice Address - Country:US
Practice Address - Phone:928-757-8589
Practice Address - Fax:928-757-0744
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW10131101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ113485OtherVALUE OPTIONS
AZ113485OtherVALUE OPTIONS