Provider Demographics
NPI:1417691387
Name:WHITE, KERRY C (LCSW)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:C
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 1:826 46TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-1553
Mailing Address - Country:US
Mailing Address - Phone:229-472-2593
Mailing Address - Fax:
Practice Address - Street 1:1824 RIDGE AVE N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3441
Practice Address - Country:US
Practice Address - Phone:229-391-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-26
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0258751041C0700X
GACSW0088851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical