Provider Demographics
NPI:1144031451
Name:WHITE, MITCHELL RAY (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:RAY
Last Name:WHITE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3560 KAREN AVE S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-5620
Mailing Address - Country:US
Mailing Address - Phone:971-241-0148
Mailing Address - Fax:
Practice Address - Street 1:5050 SKYLINE VILLAGE LOOP S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9490
Practice Address - Country:US
Practice Address - Phone:035-391-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-16
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10038148363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner