Healthcare Provider Details

I. General information

NPI: 1518687193
Provider Name (Legal Business Name): KRISTIN ROSE WHITTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S SPRING ST
TUPELO MS
38804-4822
US

IV. Provider business mailing address

PO BOX 68
TUPELO MS
38802-0068
US

V. Phone/Fax

Practice location:
  • Phone: 662-584-5097
  • Fax:
Mailing address:
  • Phone: 662-584-5097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3022
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: