Provider Demographics
NPI:1174339154
Name:WHITE, LISA MARIA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIA
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIA
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCACA
Mailing Address - Street 1:10014 PINE GROVE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-9067
Mailing Address - Country:US
Mailing Address - Phone:317-652-1524
Mailing Address - Fax:
Practice Address - Street 1:8150 BROOKVILLE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-8903
Practice Address - Country:US
Practice Address - Phone:463-224-8653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-05
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99124503A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)