Provider Demographics
NPI:1174069744
Name:WHITEHEAD, KAELA GRACE (LCSW)
Entity type:Individual
Prefix:
First Name:KAELA
Middle Name:GRACE
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 E CHALLIS DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7370
Mailing Address - Country:US
Mailing Address - Phone:208-649-4203
Mailing Address - Fax:
Practice Address - Street 1:2022 E CHALLIS DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7370
Practice Address - Country:US
Practice Address - Phone:714-261-0302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-06
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW36309101YM0800X
IDLCSW387861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health