Provider Demographics
NPI:1730576091
Name:WHITE, WILLIE DEEANJLO0 (LICDC-CS)
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:DEEANJLO0
Last Name:WHITE
Suffix:
Gender:M
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1419
Mailing Address - Country:US
Mailing Address - Phone:614-752-1290
Mailing Address - Fax:
Practice Address - Street 1:1580 STATE ROUTE 56 SW
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:OH
Practice Address - Zip Code:43140-8623
Practice Address - Country:US
Practice Address - Phone:740-852-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility