Healthcare Provider Details

I. General information

NPI: 1821203415
Provider Name (Legal Business Name): SUSAN J WHITE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12220 HARVEY ST
JONES MI
49061-9742
US

IV. Provider business mailing address

12220 HARVEY ST
JONES MI
49061-9742
US

V. Phone/Fax

Practice location:
  • Phone: 269-816-5031
  • Fax: 269-244-8913
Mailing address:
  • Phone: 269-816-5031
  • Fax: 269-244-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006308
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number35001563A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: