Basic Information
| Provider Information | |||||||||
| NPI: | 1578723771 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | ROBERTSON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | COTA/L | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7804 KAVANAGH RD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212223303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104580671 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5009 FRANKFORD AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212065353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103254000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2008 | ||||||||
| LastUpdateDate: | 06/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A00240 | MD | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | A00240 | 01 | MD | MARYLAND PROFESSIONAL LICENSE | OTHER |