MEDICARE: MS. TRACELA MICHELLE WHITE PH.D.

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	1744R1102X	Research Study Specialist	PS015143	PA
2	103TC0700X	Clinical Psychologist	PSY003238	GA

General Provider Information

NPI Number	:	1386841153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TRACELA MICHELLE WHITE PH.D.

Provider Business Mailing Address
First Line	:	1107 E UPSAL ST
Second Line	:	APT. 1
City	:	PHILADELPHIA
State	:	PA
Zip	:	19150-2601
Country	:	US
Telephone Number	:	215-548-4237
Fax Number	:

Provider Business Practice Location Address
First Line	:	34 PEACHTREE ST NW
Second Line	:	SUITE 770
City	:	ATLANTA
State	:	GA
Zip	:	30303-2316
Country	:	US
Telephone Number	:	912-557-7001
Fax Number	:

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

Provider Enumeration Date	:	06/27/2007
Last Update Date	:	02/06/2009

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