Provider Demographics
NPI:1063694545
Name:WHITE, GINA M (MA)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:M
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GENERAL DELIVERY
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-9999
Mailing Address - Country:US
Mailing Address - Phone:512-796-5994
Mailing Address - Fax:
Practice Address - Street 1:102 FRONT STREET
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548
Practice Address - Country:US
Practice Address - Phone:512-796-5994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO4808101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional