Provider Demographics
NPI:1609344639
Name:WHITE, MAKENZI LAUREN
Entity type:Individual
Prefix:
First Name:MAKENZI
Middle Name:LAUREN
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 CAROLINE CT
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:AL
Mailing Address - Zip Code:35907-5245
Mailing Address - Country:US
Mailing Address - Phone:256-438-9077
Mailing Address - Fax:
Practice Address - Street 1:221 S 4TH ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-4213
Practice Address - Country:US
Practice Address - Phone:256-459-5499
Practice Address - Fax:256-907-5155
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician