Healthcare Provider Details

I. General information

NPI: 1659401156
Provider Name (Legal Business Name): STEPHEN LEE WHITE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12600 N 113TH AVE STE C19
YOUNGTOWN AZ
85363-1125
US

IV. Provider business mailing address

5528 W.IRMA LANE
GLENDALE AZ
85308-9343
US

V. Phone/Fax

Practice location:
  • Phone: 623-764-0156
  • Fax: 623-882-1731
Mailing address:
  • Phone: 623-764-0156
  • Fax: 623-882-1731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-2955
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: