Provider Demographics
NPI:1053721076
Name:WHITE, KGOTHATSO
Entity type:Individual
Prefix:
First Name:KGOTHATSO
Middle Name:
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28475 GREENFIELD RD
Mailing Address - Street 2:STE 113 PMB 65889
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:313-327-2193
Mailing Address - Fax:
Practice Address - Street 1:28475 GREENFIELD RD
Practice Address - Street 2:STE 113 PMB 65889
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076
Practice Address - Country:US
Practice Address - Phone:313-327-2193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
FLSW160281041C0700X
MI68011043591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical