MEDICARE: MRS. DOMINECAA WHITE LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	LPC-15553	AZ

General Provider Information

NPI Number	:	1285307942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DOMINECAA WHITE LPC

Provider Business Mailing Address
First Line	:	45 E MONTEREY WAY STE 201
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2757
Country	:	US
Telephone Number	:	480-489-2866
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 E MONTEREY WAY STE 201
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85012-2757
Country	:	US
Telephone Number	:	480-489-2866
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2021
Last Update Date	:	09/01/2023

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