Provider Demographics
NPI:1104300250
Name:ISOM E WHITE LCSW, LLC
Entity type:Organization
Organization Name:ISOM E WHITE LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ISOM
Authorized Official - Middle Name:E
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:678-392-8173
Mailing Address - Street 1:1 HUNTINGTON RD STE 703
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7214
Mailing Address - Country:US
Mailing Address - Phone:706-425-8900
Mailing Address - Fax:
Practice Address - Street 1:3050 ATLANTA RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-8255
Practice Address - Country:US
Practice Address - Phone:706-425-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-24
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)