Provider Demographics
NPI:1972358398
Name:WHITELEY, KERRY
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:WHITELEY
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 1:10 N SUNSET BLVD
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4052
Mailing Address - Country:US
Mailing Address - Phone:850-712-8893
Mailing Address - Fax:
Practice Address - Street 1:913 GULF BREEZE PKWY STE 26
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4731
Practice Address - Country:US
Practice Address - Phone:850-712-8893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23038101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health