Basic Information
Provider Information | |||||||||
NPI: | 1891167888 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WHITE | ||||||||
FirstName: | TREASURE | ||||||||
MiddleName: | JAMES'E | ||||||||
NamePrefix: | PROF. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8261 SUMMA AVE STE G | ||||||||
Address2: |   | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708093452 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2252505829 | ||||||||
FaxNumber: | 2252505879 | ||||||||
Practice Location | |||||||||
Address1: | 223 FERNWOOD DR | ||||||||
Address2: | SUITE A | ||||||||
City: | BATON ROUGE | ||||||||
State: | LA | ||||||||
PostalCode: | 708063130 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2259233733 | ||||||||
FaxNumber: | 2259233735 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/29/2015 | ||||||||
LastUpdateDate: | 12/31/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 471184319 | LA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X |   |   | Y |   | Other Service Providers | Case Manager/Care Coordinator |   |
ID Information
ID | Type | State | Issuer | Description | 1194173005 | 05 | LA |   | MEDICAID |