Provider Demographics
NPI:1245883735
Name:WHITE, KAELYN (LGSW)
Entity type:Individual
Prefix:
First Name:KAELYN
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 CLIFTON PL
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403
Mailing Address - Country:US
Mailing Address - Phone:612-816-1629
Mailing Address - Fax:
Practice Address - Street 1:5354 PARKDALE DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-1603
Practice Address - Country:US
Practice Address - Phone:866-821-0281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program