Healthcare Provider Details

I. General information

NPI: 1154536324
Provider Name (Legal Business Name): THELMA JEAN WHITE L.B.S.W., M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 NORTH MAIN STREET
TUBA CITY AZ
86045-0600
US

IV. Provider business mailing address

PO BOX 206
KYKOTSMOVI AZ
86039-0206
US

V. Phone/Fax

Practice location:
  • Phone: 928-283-2951
  • Fax:
Mailing address:
  • Phone: 928-458-6719
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLBSW-11358
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: