Provider Demographics
NPI:1215139290
Name:WHITE, CARLY ANN
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
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 1:1414 SE SALMON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-3647
Mailing Address - Country:US
Mailing Address - Phone:509-989-1778
Mailing Address - Fax:
Practice Address - Street 1:1414 SE SALMON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-3647
Practice Address - Country:US
Practice Address - Phone:509-989-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor