Provider Demographics
NPI:1730682535
Name:WHITE, TANYA EULANDA (EDS QMHP, MA,)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:EULANDA
Last Name:WHITE
Suffix:
Gender:F
Credentials:EDS QMHP, MA,
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:E
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14915 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-2235
Mailing Address - Country:US
Mailing Address - Phone:708-596-4510
Mailing Address - Fax:
Practice Address - Street 1:14915 MAIN ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-2235
Practice Address - Country:US
Practice Address - Phone:708-752-6855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-18
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 103TS0200X, 376K00000X
IL2483985103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No376K00000XNursing Service Related ProvidersNurse's Aide