Provider Demographics
NPI:1013268093
Name:WHITE, STEPHANIE DIXON (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:DIXON
Last Name:WHITE
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7243 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4957
Practice Address - Country:US
Practice Address - Phone:317-446-3119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-01
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003969A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN264430032Medicare PIN