=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699370080
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIN ALEXANDRIA WHITE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2020
-----------------------------------------------------
Last Update Date | 12/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 S OLD WOODWARD AVE
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48009-6721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-537-2639
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22136 PICKFORD ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48219-2355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-354-0842
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6362006032
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------