Provider Demographics
NPI:1962426437
Name:WHITE, ELIZABETH ROSE (LICSW)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:ROSE
Last Name:WHITE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186
Mailing Address - Country:US
Mailing Address - Phone:617-698-0770
Mailing Address - Fax:
Practice Address - Street 1:21 TOTMAN ST
Practice Address - Street 2:FLOOR 2
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-698-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALICSW10334103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
008084OtherVALU OPTION
P02053OtherBLUE CROSS
42431OtherHARVARD PILGRIM
722930OtherTUFTS HEALTH PO
008084OtherVALU OPTION