Provider Demographics
NPI:1881872752
Name:WOODSON WHITE, ALICE MIRIAM MARJORIE (LCSW-R, CASAC)
Entity type:Individual
Prefix:MS
First Name:ALICE
Middle Name:MIRIAM MARJORIE
Last Name:WOODSON WHITE
Suffix:
Gender:F
Credentials:LCSW-R, CASAC
Other - Prefix:MRS
Other - First Name:ALICE
Other - Middle Name:WOODSON
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW-R, CASAC
Mailing Address - Street 1:PO BOX 2381
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-0741
Mailing Address - Country:US
Mailing Address - Phone:631-675-9494
Mailing Address - Fax:631-675-9494
Practice Address - Street 1:249 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2919
Practice Address - Country:US
Practice Address - Phone:631-675-9494
Practice Address - Fax:631-675-9494
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY73-0810111041C0700X, 101YM0800X
NY29000101YA0400X
NY074544-1101YM0800X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03042968Medicaid