Provider Demographics
NPI:1568792935
Name:WHITE, FAY (MED, LADC 1)
Entity type:Individual
Prefix:MS
First Name:FAY
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:MED, LADC 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 ESMOND ST
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02121-4006
Mailing Address - Country:US
Mailing Address - Phone:617-822-5133
Mailing Address - Fax:
Practice Address - Street 1:58 ESMOND ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-4006
Practice Address - Country:US
Practice Address - Phone:617-822-5133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2025-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MA18180101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health