Basic Information
| Provider Information | |||||||||
| NPI: | 1326130048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 104 COLONY WAY | ||||||||
| Address2: | |||||||||
| City: | NITRO | ||||||||
| State: | WV | ||||||||
| PostalCode: | 251431034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3045251073 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 LINCOLN PLZ | ||||||||
| Address2: | |||||||||
| City: | BRANCHLAND | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255069786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045257851 | ||||||||
| FaxNumber: | 3045251073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | AP00940280 | WV | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | AP00940280 | 01 | WV | LSW | OTHER |