=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831404011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAKEAH WHITE MS, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2010
-----------------------------------------------------
Last Update Date | 02/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 912 KILLIAN HILL ROAD SUITE 202-C
-----------------------------------------------------
City | LILBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-415-8629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6800 TIMBERCLAIR CT
-----------------------------------------------------
City | LITHONIA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30058-6057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-415-8629
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 011260
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------