MEDICARE: DEIRDRE ANDERSON-WHITE PH.D., LPC

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	101YM0800X	Mental Health Counselor	LPC007063	GA
2	101YP2500X	Professional Counselor	LPC007063	GA

General Provider Information

NPI Number	:	1447627906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEIRDRE ANDERSON-WHITE PH.D., LPC

Provider Business Mailing Address
First Line	:	138 CANAL ST
Second Line	:	UNIT 307
City	:	POOLER
State	:	GA
Zip	:	31322-4051
Country	:	US
Telephone Number	:	912-348-3486
Fax Number	:	912-348-3489

Provider Business Practice Location Address
First Line	:	138 CANAL ST
Second Line	:	UNIT 307
City	:	POOLER
State	:	GA
Zip	:	31322-4051
Country	:	US
Telephone Number	:	912-348-3486
Fax Number	:	912-348-3489

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

Provider Enumeration Date	:	08/31/2015
Last Update Date	:	08/31/2015

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