Provider Demographics
NPI:1063795110
Name:WHITE, KENNETH H (MSW)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:H
Last Name:WHITE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W MITCHELL ST
Mailing Address - Street 2:#223
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3383
Mailing Address - Country:US
Mailing Address - Phone:414-383-4455
Mailing Address - Fax:414-433-0171
Practice Address - Street 1:1225 W MITCHELL ST
Practice Address - Street 2:#223
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3383
Practice Address - Country:US
Practice Address - Phone:414-383-4455
Practice Address - Fax:414-433-0171
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16394-130101YA0400X
WI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI16394-130OtherWI LICENSE SAC-IT