Provider Demographics
NPI:1780812909
Name:WHITE, KIMBERLY DAWN (MED, ICADC)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:WHITE
Suffix:
Gender:F
Credentials:MED, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 MICHAEL DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5227
Mailing Address - Country:US
Mailing Address - Phone:405-285-1632
Mailing Address - Fax:
Practice Address - Street 1:2628 MICHAEL DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5227
Practice Address - Country:US
Practice Address - Phone:405-285-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)