Provider Demographics
NPI:1427879022
Name:WHITE, JOAN M
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:M
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 1:4505 KIMBALL LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-3212
Mailing Address - Country:US
Mailing Address - Phone:336-682-0262
Mailing Address - Fax:336-600-2350
Practice Address - Street 1:4505 KIMBALL LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-3212
Practice Address - Country:US
Practice Address - Phone:336-682-0262
Practice Address - Fax:336-600-2350
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC034-417320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities