Provider Demographics
NPI:1770158990
Name:WHITWORTH, KALEB SHANE (LPCA)
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:SHANE
Last Name:WHITWORTH
Suffix:
Gender:M
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 WHITE RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-5040
Mailing Address - Country:US
Mailing Address - Phone:615-516-1610
Mailing Address - Fax:
Practice Address - Street 1:736 WHITE RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-5040
Practice Address - Country:US
Practice Address - Phone:615-516-1610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246270101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health