Healthcare Provider Details

I. General information

NPI: 1982946737
Provider Name (Legal Business Name): LIZA WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 06/26/2023
Certification Date: 06/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3138 BRACHENBURY LANE
JACKSONVILLE FL
32225-1037
US

IV. Provider business mailing address

5027 PEACH MOUNTAIN CIR
GAINESVILLE GA
30507-1423
US

V. Phone/Fax

Practice location:
  • Phone: 502-599-4747
  • Fax: 502-589-8771
Mailing address:
  • Phone: 502-599-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH20874
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: