Healthcare Provider Details

I. General information

NPI: 1346444544
Provider Name (Legal Business Name): MARILYN L WHITE B.S.ACC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 LAWTON ST
DETROIT MI
48208-2500
US

IV. Provider business mailing address

5311 HOLCOMB ST
DETROIT MI
48213-3021
US

V. Phone/Fax

Practice location:
  • Phone: 313-361-6136
  • Fax:
Mailing address:
  • Phone: 313-361-6136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: