Provider Demographics
NPI:1750404331
Name:WHITE, KENNETH SHANE (PT, WCC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:SHANE
Last Name:WHITE
Suffix:
Gender:M
Credentials:PT, WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:ATMORE
Mailing Address - State:AL
Mailing Address - Zip Code:36502-3306
Mailing Address - Country:US
Mailing Address - Phone:251-368-2726
Mailing Address - Fax:
Practice Address - Street 1:401 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ATMORE
Practice Address - State:AL
Practice Address - Zip Code:36502-3006
Practice Address - Country:US
Practice Address - Phone:251-368-6346
Practice Address - Fax:251-368-6255
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH3582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist