1063489862 NPI number — DR. CHARLA JEANINE WHITE

Table of content: DR. CHARLA JEANINE WHITE (NPI 1063489862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063489862 NPI number — DR. CHARLA JEANINE WHITE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
CHARLA
Provider Middle Name:
JEANINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIGGINS
Provider Other First Name:
CHARLA
Provider Other Middle Name:
JEANINE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063489862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2997 STOCKHOLM WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBRIDGE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22191-4286
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-680-5146
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9625 SURVEYOR CT
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MANASSAS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20110-4422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-330-9933
Provider Business Practice Location Address Fax Number:
703-368-8454
Provider Enumeration Date:
03/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  0810003345 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0515622 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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