Healthcare Provider Details

I. General information

NPI: 1063285252
Provider Name (Legal Business Name): MR. KERRY DONOVAN WHITE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

223 E THOUSAND OAKS BLVD STE 103
THOUSAND OAKS CA
91360-7706
US

IV. Provider business mailing address

1396 SHEFFIELD PL
THOUSAND OAKS CA
91360-5242
US

V. Phone/Fax

Practice location:
  • Phone: 818-268-5338
  • Fax:
Mailing address:
  • Phone: 818-268-5338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: