Provider Demographics
NPI:1306551304
Name:WHITE, REA LYN
Entity type:Individual
Prefix:
First Name:REA
Middle Name:LYN
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 1:808 BIRCHCREST DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28677-3188
Mailing Address - Country:US
Mailing Address - Phone:704-880-1202
Mailing Address - Fax:
Practice Address - Street 1:105 HIDDENITE CHURCH RD
Practice Address - Street 2:
Practice Address - City:HIDDENITE
Practice Address - State:NC
Practice Address - Zip Code:28636-8168
Practice Address - Country:US
Practice Address - Phone:704-880-1202
Practice Address - Fax:828-471-3318
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-16
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18440101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional