1629336177 NPI number — KRISTI RENEE WHITE L.C.S.W.

Table of content: KRISTI RENEE WHITE L.C.S.W. (NPI 1629336177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629336177 NPI number — KRISTI RENEE WHITE L.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITE
Provider First Name:
KRISTI
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ZIMMERMAN
Provider Other First Name:
KRISTI
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629336177
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
423 N MARKET ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64468-1614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-562-3000
Provider Business Mailing Address Fax Number:
660-562-3002

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
423 N MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-562-3000
Provider Business Practice Location Address Fax Number:
660-562-3002
Provider Enumeration Date:
05/02/2012

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: 1041C0700X , with the licence number:  2012003645 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1629336177 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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