Provider Demographics
NPI:1326130048
Name:WHITE, KEVIN M (LSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:WHITE
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 COLONY WAY
Mailing Address - Street 2:
Mailing Address - City:NITRO
Mailing Address - State:WV
Mailing Address - Zip Code:25143-1034
Mailing Address - Country:US
Mailing Address - Phone:304-525-7851
Mailing Address - Fax:304-525-1073
Practice Address - Street 1:25 LINCOLN PLZ
Practice Address - Street 2:
Practice Address - City:BRANCHLAND
Practice Address - State:WV
Practice Address - Zip Code:25506-9786
Practice Address - Country:US
Practice Address - Phone:304-525-7851
Practice Address - Fax:304-525-1073
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAP009402801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVAP00940280OtherLSW