Healthcare Provider Details

I. General information

NPI: 1972184265
Provider Name (Legal Business Name): TANESHA ASHLEY NICOLE WHITE LPCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1169 EASTERN PKWY STE 3364
LOUISVILLE KY
40217-1415
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 502-813-8280
  • Fax: 502-473-1334
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number261996
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: