Healthcare Provider Details

I. General information

NPI: 1083022644
Provider Name (Legal Business Name): ERICA WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2014
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 RESOURCE LN
WINDER GA
30680-8361
US

IV. Provider business mailing address

204 RESOURCE LN
WINDER GA
30680-8361
US

V. Phone/Fax

Practice location:
  • Phone: 678-963-0694
  • Fax: 888-547-4008
Mailing address:
  • Phone: 678-963-0694
  • Fax: 888-547-4008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT005951
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: