Provider Demographics
NPI:1558427369
Name:WHITE, KIMBERLY ANN (MA, LICSW)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MA, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 UNIVERSITY AVE W STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3435
Mailing Address - Country:US
Mailing Address - Phone:651-266-7901
Mailing Address - Fax:651-266-7854
Practice Address - Street 1:1919 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3453
Practice Address - Country:US
Practice Address - Phone:651-266-7901
Practice Address - Fax:651-266-7854
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN896484000Medicaid