Provider Demographics
NPI:1114735321
Name:HEATH WHITE, PHYLLIS
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:HEATH WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80259 LILLIAN RD
Mailing Address - Street 2:
Mailing Address - City:BROKEN BOW
Mailing Address - State:NE
Mailing Address - Zip Code:68822-5507
Mailing Address - Country:US
Mailing Address - Phone:308-872-2742
Mailing Address - Fax:
Practice Address - Street 1:717 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:NE
Practice Address - Zip Code:68822-2521
Practice Address - Country:US
Practice Address - Phone:308-872-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services