1063795110 NPI number — KENNETH H WHITE MSW

Table of content: KENNETH H WHITE MSW (NPI 1063795110)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063795110 NPI number — KENNETH H WHITE MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
KENNETH
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063795110
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/21/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1225 W MITCHELL ST
Provider Second Line Business Mailing Address:
#223
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53204-3383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-383-4455
Provider Business Mailing Address Fax Number:
414-433-0171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 W MITCHELL ST
Provider Second Line Business Practice Location Address:
#223
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53204-3383
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-383-4455
Provider Business Practice Location Address Fax Number:
414-433-0171
Provider Enumeration Date:
09/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  16394-130 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 104100000X , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 16394-130 . This is a "WI LICENSE SAC-IT" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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