Provider Demographics
NPI:1891590105
Name:WHITE, THEA (LMT)
Entity type:Individual
Prefix:
First Name:THEA
Middle Name:
Last Name:WHITE
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9603 N 5TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2084
Mailing Address - Country:US
Mailing Address - Phone:602-688-3435
Mailing Address - Fax:
Practice Address - Street 1:801 W MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1325
Practice Address - Country:US
Practice Address - Phone:602-688-3435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-29996225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist