Healthcare Provider Details

I. General information

NPI: 1841502192
Provider Name (Legal Business Name): THERESA ANN WHITE M.A., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 REDMOND RD
WESTPORT NY
12993-2529
US

IV. Provider business mailing address

150 REDMOND RD
WESTPORT NY
12993-2529
US

V. Phone/Fax

Practice location:
  • Phone: 518-536-2537
  • Fax: 518-837-2009
Mailing address:
  • Phone: 518-536-2537
  • Fax: 518-837-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number019567-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: