Provider Demographics
NPI:1518419514
Name:WHITE, KRISTINA MARIA (MED; LMFT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:MARIA
Last Name:WHITE
Suffix:
Gender:F
Credentials:MED; LMFT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MARIA
Other - Last Name:HIMMELBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1414 HICKORY ST.
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578
Mailing Address - Country:US
Mailing Address - Phone:850-598-1738
Mailing Address - Fax:
Practice Address - Street 1:348 MIRACLE STRIP PARKWAY SUITE B-3
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548
Practice Address - Country:US
Practice Address - Phone:850-862-3772
Practice Address - Fax:850-863-4574
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
FL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103563500Medicaid