Healthcare Provider Details

I. General information

NPI: 1043570187
Provider Name (Legal Business Name): KRISTLE R. WHITE M.A., TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35640 W MICHIGAN AVE
WAYNE MI
48184-1628
US

IV. Provider business mailing address

11187 JIM PL
WARREN MI
48089-1069
US

V. Phone/Fax

Practice location:
  • Phone: 734-729-7792
  • Fax: 734-729-7938
Mailing address:
  • Phone: 586-770-9978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberL1950490
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: