Healthcare Provider Details

I. General information

NPI: 1821106725
Provider Name (Legal Business Name): BRIAN WHITE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 W MAIN ST
DECATURVILLE TN
38329-8033
US

IV. Provider business mailing address

10710 OLD HIGHWAY 64
BOLIVAR TN
38008-3587
US

V. Phone/Fax

Practice location:
  • Phone: 731-852-3112
  • Fax: 731-852-3222
Mailing address:
  • Phone: 731-658-6113
  • Fax: 731-658-1597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLSW 3864
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: