Provider Demographics
NPI:1043038268
Name:WHITE, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9825 MAYBERRY LN
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-3051
Mailing Address - Country:US
Mailing Address - Phone:208-713-1290
Mailing Address - Fax:
Practice Address - Street 1:9825 MAYBERRY LN
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-3051
Practice Address - Country:US
Practice Address - Phone:208-713-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities