Provider Demographics
NPI:1174076046
Name:DAVID AND DELORES WHITE
Entity type:Organization
Organization Name:DAVID AND DELORES WHITE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELORES
Authorized Official - Middle Name:EVENS
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:361-572-0202
Mailing Address - Street 1:4702 N LAURENT ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2147
Mailing Address - Country:US
Mailing Address - Phone:361-572-0202
Mailing Address - Fax:361-572-0300
Practice Address - Street 1:4702 N LAURENT ST
Practice Address - Street 2:SUITE D
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2147
Practice Address - Country:US
Practice Address - Phone:361-572-0202
Practice Address - Fax:361-572-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66862251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX305544401Medicaid