=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366441578
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMRA WHITE LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2005
-----------------------------------------------------
Last Update Date | 11/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2485 E SOUTHLAKE BLVD SUITE 180
-----------------------------------------------------
City | SOUTHLAKE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76092-6686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-224-0105
-----------------------------------------------------
Fax | 817-488-9656
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2705 BRITTANY LN
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-4302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-224-0105
-----------------------------------------------------
Fax | 817-488-9656
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 16685
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------