Healthcare Provider Details

I. General information

NPI: 1811910052
Provider Name (Legal Business Name): SUSANNA HEIKE WHITE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13160 CTY RD 3610
ST. JAMES MO
65559
US

IV. Provider business mailing address

11360 PRIVATE DRIVE 5316
ROLLA MO
65401-7675
US

V. Phone/Fax

Practice location:
  • Phone: 573-265-3251
  • Fax: 573-265-0156
Mailing address:
  • Phone: 573-578-6858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2003018369
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: