Provider Demographics
NPI:1093257297
Name:WHITE, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 ARBOR ST STE 106
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1223
Mailing Address - Country:US
Mailing Address - Phone:860-930-6745
Mailing Address - Fax:860-967-0343
Practice Address - Street 1:56 ARBOR ST STE 106
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1223
Practice Address - Country:US
Practice Address - Phone:860-930-6745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-06
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2978101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008068845Medicaid