Provider Demographics
NPI:1144704768
Name:WHITE, STACY
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE, ML 3015
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229
Mailing Address - Country:US
Mailing Address - Phone:513-636-4336
Mailing Address - Fax:513-636-7756
Practice Address - Street 1:3333 BURNET AVE, ML 3015
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229
Practice Address - Country:US
Practice Address - Phone:513-636-4336
Practice Address - Fax:513-636-7756
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
OH390200000X
OHP.08208103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid