Provider Demographics
NPI:1811427735
Name:WHITE, DEMETRIC SHONDRELL
Entity type:Individual
Prefix:
First Name:DEMETRIC
Middle Name:SHONDRELL
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 KINGSTON DR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-3139
Mailing Address - Country:US
Mailing Address - Phone:318-527-1391
Mailing Address - Fax:
Practice Address - Street 1:325 SOUTH DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5060
Practice Address - Country:US
Practice Address - Phone:318-228-3197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health