MEDICARE: ANGELINE LEE WHITE

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	103K00000X	Behavior Analyst		IL

General Provider Information

NPI Number	:	1457120834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELINE LEE WHITE

Provider Business Mailing Address
First Line	:	7554 S COLES AVE APT 3B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4346
Country	:	US
Telephone Number	:	312-244-9299
Fax Number	:

Provider Business Practice Location Address
First Line	:	7554 S COLES AVE APT 3B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-4346
Country	:	US
Telephone Number	:	312-244-9299
Fax Number	:

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

Provider Enumeration Date	:	12/27/2023
Last Update Date	:	12/27/2023

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