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General NPI Number Information
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NPI Number | 1134481658
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Entity Type | Individual
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Provider Name | GRANT WHITE III PSY.D.
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Gender | Male
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Dates
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Enumeration Date | 06/11/2012
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Last Update Date | 06/11/2012
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Provider Practice Location Address
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Address Line | 222 MERCHANDISE MART PLZ SUITE 13-659 ROOM #1352
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City | CHICAGO
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State | IL
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Zip | 60654-1103
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Country | US
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Telephone | 708-207-8074
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Fax | 708-679-0015
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Provider Business Mailing Address
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Address Line | 23002 AMBER LN
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City | RICHTON PARK
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State | IL
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Zip | 60471-1282
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Country | US
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Telephone | 708-503-9880
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Fax | 708-679-0015
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071-005123
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License Number State | IL
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