Provider Demographics
NPI:1528559663
Name:WHITE, KRISTIN T (LICSW)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:T
Last Name:WHITE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-3863
Mailing Address - Country:US
Mailing Address - Phone:304-704-8936
Mailing Address - Fax:
Practice Address - Street 1:100 TYLER AVE
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-3863
Practice Address - Country:US
Practice Address - Phone:304-704-8936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
WVDP009451301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker