Healthcare Provider Details

I. General information

NPI: 1376128389
Provider Name (Legal Business Name): SHAWNRICA WHITE CASE MANAGER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 WAYNE AVE BLDG 61
DAYTON OH
45420-1833
US

IV. Provider business mailing address

6400 E BROAD ST FL 4
COLUMBUS OH
43213-2086
US

V. Phone/Fax

Practice location:
  • Phone: 937-228-0579
  • Fax:
Mailing address:
  • Phone: 614-655-3345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-159349
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: