Provider Demographics
NPI:1912153685
Name:WHITE, PHYLLIS LYNN (M A, M DIV, LMFT)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:LYNN
Last Name:WHITE
Suffix:
Gender:F
Credentials:M A, M DIV, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18161 MORRIS AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-2141
Mailing Address - Country:US
Mailing Address - Phone:708-296-6005
Mailing Address - Fax:
Practice Address - Street 1:18161 MORRIS AVE STE 208
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-2141
Practice Address - Country:US
Practice Address - Phone:708-296-6005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-13
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000913106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist