Healthcare Provider Details

I. General information

NPI: 1730824095
Provider Name (Legal Business Name): TONLAVAIL J WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5725 ROSE CT
BERKELEY IL
60163-1548
US

IV. Provider business mailing address

5725 ROSE CT
BERKELEY IL
60163-1548
US

V. Phone/Fax

Practice location:
  • Phone: 708-431-5284
  • Fax:
Mailing address:
  • Phone: 708-431-5284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149010846
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: