Healthcare Provider Details

I. General information

NPI: 1003256744
Provider Name (Legal Business Name): TAKIEDRA WHITE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 10/05/2023
Certification Date: 10/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 HOWELL MILL RD NW STE 800
ATLANTA GA
30318-5557
US

IV. Provider business mailing address

1055 HOWELL MILL RD NW STE 800
ATLANTA GA
30318-5557
US

V. Phone/Fax

Practice location:
  • Phone: 404-692-6913
  • Fax:
Mailing address:
  • Phone: 404-692-6913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC009512
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009512
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: