Healthcare Provider Details

I. General information

NPI: 1750506945
Provider Name (Legal Business Name): SUSAN WHITE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2007
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 S PEORIA ST SUITE 206
LOUISBURG KS
66053-4084
US

IV. Provider business mailing address

5 S PEORIA ST SUITE 206
LOUISBURG KS
66053-4084
US

V. Phone/Fax

Practice location:
  • Phone: 913-837-4919
  • Fax: 913-837-4923
Mailing address:
  • Phone: 913-837-4919
  • Fax: 913-837-4923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number584
License Number StateKS

VIII. Authorized Official

Name: MS. SUSAN GAYLE WHITE
Title or Position: EXECUTIVE DIRECTOR
Credential: LMSW, CADCIII
Phone: 913-837-4919