MEDICARE: PHYLLIS LYNN WHITE M. A., M. DIV., LMFT

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	106H00000X	Marriage & Family Therapist	166.000913	IL

General Provider Information

NPI Number	:	1912153685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS LYNN WHITE M. A., M. DIV., LMFT

Provider Business Mailing Address
First Line	:	18161 MORRIS AVE STE 208
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-2141
Country	:	US
Telephone Number	:	708-296-6005
Fax Number	:

Provider Business Practice Location Address
First Line	:	18161 MORRIS AVE STE 208
Second Line	:
City	:	HOMEWOOD
State	:	IL
Zip	:	60430-2141
Country	:	US
Telephone Number	:	708-296-6005
Fax Number	:

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

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	05/09/2013

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