Provider Demographics
NPI:1902156102
Name:WHITE, KRISTIN KELLY (BA)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:KELLY
Last Name:WHITE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:MISS
Other - First Name:KRISTIN
Other - Middle Name:KELLY
Other - Last Name:BROSI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:2913 CYPRESS BOWL RD
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558
Mailing Address - Country:US
Mailing Address - Phone:813-817-3358
Mailing Address - Fax:813-971-2915
Practice Address - Street 1:2913 CYPRESS BOWL RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558
Practice Address - Country:US
Practice Address - Phone:813-817-3358
Practice Address - Fax:813-971-2915
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FLMH20082101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251B00000XAgenciesCase Management