Provider Demographics
NPI:1194282434
Name:WHITE, ELISHIA
Entity type:Individual
Prefix:
First Name:ELISHIA
Middle Name:
Last Name: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 1:302 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:PADEN
Mailing Address - State:OK
Mailing Address - Zip Code:74860-9233
Mailing Address - Country:US
Mailing Address - Phone:405-203-8567
Mailing Address - Fax:
Practice Address - Street 1:1127 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-4845
Practice Address - Country:US
Practice Address - Phone:405-214-0116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional