Provider Demographics
NPI:1730614033
Name:WHITE, IVAN
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6025 SE 46TH AVENUE RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34480-7765
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15681 N US HIGHWAY 301
Practice Address - Street 2:
Practice Address - City:CITRA
Practice Address - State:FL
Practice Address - Zip Code:32113-3154
Practice Address - Country:US
Practice Address - Phone:352-595-5000
Practice Address - Fax:352-595-8431
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLADC-006927-2015101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)