Healthcare Provider Details

I. General information

NPI: 1801261292
Provider Name (Legal Business Name): KELLY H WHITE M.A., M.ED, LPC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W LEAKE ST STE 3
CLINTON MS
39056-4253
US

IV. Provider business mailing address

PO BOX 534
CLINTON MS
39060-0534
US

V. Phone/Fax

Practice location:
  • Phone: 318-278-7904
  • Fax:
Mailing address:
  • Phone: 318-278-7904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2599
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5580
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: