Provider Demographics
NPI:1144972753
Name:WHITE, AMBRYA ANDE (LCSW)
Entity type:Individual
Prefix:
First Name:AMBRYA
Middle Name:ANDE
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:AMBRYA
Other - Middle Name:ANDE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:393 E 2ND N
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1605
Mailing Address - Country:US
Mailing Address - Phone:208-359-4840
Mailing Address - Fax:208-359-9010
Practice Address - Street 1:393 E 2ND N
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1605
Practice Address - Country:US
Practice Address - Phone:208-359-4840
Practice Address - Fax:208-359-9010
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-41727104100000X
ID88618411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker