MEDICARE: TYIESHA LEE WHITE M.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician	2022046188	MO
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	7995	MO

General Provider Information

NPI Number	:	1326880873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYIESHA LEE WHITE M.A.

Provider Business Mailing Address
First Line	:	104 HENDERSON ST
Second Line	:
City	:	TROY
State	:	IL
Zip	:	62294-1114
Country	:	US
Telephone Number	:	573-353-3642
Fax Number	:

Provider Business Practice Location Address
First Line	:	104 HENDERSON ST
Second Line	:
City	:	TROY
State	:	IL
Zip	:	62294-1114
Country	:	US
Telephone Number	:	573-353-3642
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2024
Last Update Date	:	06/06/2024

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