Basic Information
| Provider Information | |||||||||
| NPI: | 1265444822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | DARRYL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1576 WELLMAN DR SE | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396014728 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1701 WHITE ST | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016842173 | ||||||||
| FaxNumber: | 6042494234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | M3168 | MS | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.