Provider Demographics
NPI:1427737402
Name:WHITE, SHALISE (RBT)
Entity type:Individual
Prefix:
First Name:SHALISE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4985 UNION ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-1431
Mailing Address - Country:US
Mailing Address - Phone:404-245-3351
Mailing Address - Fax:
Practice Address - Street 1:4985 UNION ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-1431
Practice Address - Country:US
Practice Address - Phone:404-245-3351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062200687106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician