Basic Information
| Provider Information | |||||||||
| NPI: | 1013373562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | ALICIA | ||||||||
| MiddleName: | JACLYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VEGA | ||||||||
| OtherFirstName: | ALICIA | ||||||||
| OtherMiddleName: | JACLYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3500 DEPAUW BOULEVARD | ||||||||
| Address2: | SUITE 3070 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462686135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8553240885 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Practice Location | |||||||||
| Address1: | 17390 DUGDALE DRIVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351512 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5744002169 | ||||||||
| FaxNumber: | 7654506664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2016 | ||||||||
| LastUpdateDate: | 08/14/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-15-21144 | IN | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 300009394 | 05 | IN | MEDICAID | 1-15-21144 | 01 | BCBA CERTIFICATE | OTHER |