Provider Demographics
NPI:1518475268
Name:WHITE, KEITH DOUGLAS
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:DOUGLAS
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12050 LAKE AVE APT 504
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1872
Mailing Address - Country:US
Mailing Address - Phone:216-231-3772
Mailing Address - Fax:216-231-3772
Practice Address - Street 1:12050 LAKE AVE APT 504
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-1872
Practice Address - Country:US
Practice Address - Phone:216-231-3772
Practice Address - Fax:216-231-3772
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN960110101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)