Healthcare Provider Details

I. General information

NPI: 1205412400
Provider Name (Legal Business Name): KYLA E WHITE LMHC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W MAIN ST STE A4
NORTHBOROUGH MA
01532-2132
US

IV. Provider business mailing address

300 W MAIN ST STE A4
NORTHBOROUGH MA
01532-2132
US

V. Phone/Fax

Practice location:
  • Phone: 508-422-0024
  • Fax:
Mailing address:
  • Phone: 508-422-0024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KYLA WHITE
Title or Position: PRESIDENT, PROVIDER
Credential: LMHC, LADC
Phone: 508-422-0024