MEDICARE: BROOKE WHITE PHD

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	103TC0700X	Clinical Psychologist	048.0074506	VT

General Provider Information

NPI Number	:	1447318597
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE WHITE PHD

Provider Business Mailing Address
First Line	:	73 MAIN ST
Second Line	:	SUITE 19
City	:	MONTPELIER
State	:	VT
Zip	:	05602-2932
Country	:	US
Telephone Number	:	802-505-1748
Fax Number	:

Provider Business Practice Location Address
First Line	:	73 MAIN ST
Second Line	:	SUITE 19
City	:	MONTPELIER
State	:	VT
Zip	:	05602-2932
Country	:	US
Telephone Number	:	802-505-1748
Fax Number	:

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

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	06/08/2011

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