Healthcare Provider Details

I. General information

NPI: 1477734465
Provider Name (Legal Business Name): WILLIAM EUGENE WHITE JR. LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2007
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13160 COUNTY RD 3610
ST. JAMES MO
65559-9999
US

IV. Provider business mailing address

11360 PVT DR 5613
ROLLA MO
65401-9808
US

V. Phone/Fax

Practice location:
  • Phone: 573-578-2289
  • Fax: 573-426-3076
Mailing address:
  • Phone: 573-578-2289
  • Fax: 573-426-3076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2007033159
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: