Provider Demographics
NPI:1417493644
Name:WHITE, KAY B (LCSW)
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:B
Last Name:WHITE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 E EMPIRE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3252
Mailing Address - Country:US
Mailing Address - Phone:309-310-6719
Mailing Address - Fax:309-827-7576
Practice Address - Street 1:712 E EMPIRE ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3252
Practice Address - Country:US
Practice Address - Phone:309-310-6719
Practice Address - Fax:309-827-7576
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-0000071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical