MEDICARE: MARK ALLEN WHITE M.M.F.T.

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	106H00000X	Marriage & Family Therapist	200985	TX

General Provider Information

NPI Number	:	1689880221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ALLEN WHITE M.M.F.T.

Provider Business Mailing Address
First Line	:	5408 16TH ST
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79416-5404
Country	:	US
Telephone Number	:	806-785-1697
Fax Number	:

Provider Business Practice Location Address
First Line	:	3311 81ST ST
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79423-2043
Country	:	US
Telephone Number	:	806-780-0003
Fax Number	:

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

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	07/08/2007

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