Healthcare Provider Details

I. General information

NPI: 1497397566
Provider Name (Legal Business Name): ODETTE WHITE EAGLE MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2019
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 TOWN LINE RD STE 3
WETHERSFIELD CT
06109-4316
US

IV. Provider business mailing address

27 TOWN LINE RD STE 3
WETHERSFIELD CT
06109-4316
US

V. Phone/Fax

Practice location:
  • Phone: 860-414-5457
  • Fax:
Mailing address:
  • Phone: 860-414-5457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15123
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: