Provider Demographics
NPI:1972132199
Name:WHITE, EDNA J
Entity type:Individual
Prefix:
First Name:EDNA
Middle Name:J
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 1:11 W MAIN ST APT 311
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2800
Mailing Address - Country:US
Mailing Address - Phone:631-295-8631
Mailing Address - Fax:
Practice Address - Street 1:11 W MAIN ST APT 311
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2800
Practice Address - Country:US
Practice Address - Phone:631-295-8631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-08
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1972132199Medicaid
NY04082020725525Medicaid