Provider Demographics
NPI:1801133657
Name:WHITE, KENNETH RAY (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:RAY
Last Name:WHITE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SW PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1943
Mailing Address - Country:US
Mailing Address - Phone:772-873-8811
Mailing Address - Fax:772-873-8800
Practice Address - Street 1:512 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-1943
Practice Address - Country:US
Practice Address - Phone:772-873-8811
Practice Address - Fax:772-873-8800
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-14
Last Update Date:2013-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical