Provider Demographics
NPI:1699576371
Name:WHITE, EDELE DESIR
Entity type:Individual
Prefix:
First Name:EDELE
Middle Name:DESIR
Last Name:WHITE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11503 CANOPY LOOP
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-9457
Mailing Address - Country:US
Mailing Address - Phone:786-290-5525
Mailing Address - Fax:305-917-3169
Practice Address - Street 1:11503 CANOPY LOOP
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-9457
Practice Address - Country:US
Practice Address - Phone:786-290-5525
Practice Address - Fax:305-917-3169
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-20
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-381588106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician