Provider Demographics
NPI:1730840935
Name:WHITE, PEARL MAE
Entity type:Individual
Prefix:
First Name:PEARL
Middle Name:MAE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PEARL
Other - Middle Name:MAE
Other - Last Name:BONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3007 HARBOR LN N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5103
Mailing Address - Country:US
Mailing Address - Phone:612-261-1898
Mailing Address - Fax:
Practice Address - Street 1:3007 HARBOR LN N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5103
Practice Address - Country:US
Practice Address - Phone:612-261-1898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other