Provider Demographics
NPI:1619333036
Name:WHITE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8512 SIX FORKS RD STE 101
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3256
Mailing Address - Country:US
Mailing Address - Phone:919-277-0253
Mailing Address - Fax:919-277-4627
Practice Address - Street 1:8512 SIX FORKS RD STE 101
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3256
Practice Address - Country:US
Practice Address - Phone:919-277-0253
Practice Address - Fax:919-277-4627
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0101411041C0700X
NCC0112191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical