Provider Demographics
NPI:1962546911
Name:WHITE, FREDERICK A (PHD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:A
Last Name:WHITE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:READFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04355-3340
Mailing Address - Country:US
Mailing Address - Phone:207-662-6201
Mailing Address - Fax:888-765-8406
Practice Address - Street 1:169 SOUTH RD
Practice Address - Street 2:
Practice Address - City:READFIELD
Practice Address - State:ME
Practice Address - Zip Code:04355-3340
Practice Address - Country:US
Practice Address - Phone:207-622-6201
Practice Address - Fax:888-765-8406
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2020-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS858103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME018300OtherANTHEM
ME228960000Medicaid
MEMM6526Medicare ID - Type Unspecified