Provider Demographics
NPI:1518015098
Name:WHITE, KELLY DEAN (NCC, LPC, LCAS)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DEAN
Last Name:WHITE
Suffix:
Gender:F
Credentials:NCC, LPC, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5949E QUAIL HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210
Mailing Address - Country:US
Mailing Address - Phone:704-336-6639
Mailing Address - Fax:
Practice Address - Street 1:429 BILLINGSLEY RD
Practice Address - Street 2:MECKLENBURG SUBSTANCE ABUSE SERVICES CENTER
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1007
Practice Address - Country:US
Practice Address - Phone:704-336-6669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1068101YA0400X
NC3236101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102837Medicaid