Healthcare Provider Details

I. General information

NPI: 1750991576
Provider Name (Legal Business Name): IMANI WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 05/30/2024
Certification Date: 12/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 PEMBERTON HILL RD STE 202
APEX NC
27502-4266
US

IV. Provider business mailing address

2421 LANDMARK DR APT 330
RALEIGH NC
27607-2806
US

V. Phone/Fax

Practice location:
  • Phone: 919-627-8599
  • Fax:
Mailing address:
  • Phone: 919-627-8599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number102494
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberP017327
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP017327
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: