Healthcare Provider Details

I. General information

NPI: 1124276134
Provider Name (Legal Business Name): MICHELE MARIE MATTSON WHITE LCPC, LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CATHEDRAL ST
BALTIMORE MD
21201-5442
US

IV. Provider business mailing address

1001 CATHEDRAL ST
BALTIMORE MD
21201-5442
US

V. Phone/Fax

Practice location:
  • Phone: 410-496-6441
  • Fax:
Mailing address:
  • Phone: 410-496-6441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC2979
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLGA1533
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: