Individual
TYIESHA LEE WHITE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.A.
Contact information
Practice address
104 HENDERSON ST, TROY, IL 62294-1114
(573) 353-3642
Mailing address
104 HENDERSON ST, TROY, IL 62294-1114
(573) 353-3642
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
7995
MO
247200000X
Other Technician
2022046188
MO
Other
Enumeration date
06/06/2024
Last updated
06/06/2024
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