Basic Information
| Provider Information | |||||||||
| NPI: | 1558334292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LPC LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 817 | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433570817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374658065 | ||||||||
| FaxNumber: | 9374653505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1521 N DETROIT ST | ||||||||
| Address2: | |||||||||
| City: | WEST LIBERTY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433570817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374658065 | ||||||||
| FaxNumber: | 9374653505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | C0005786 | OH | X | Behavioral Health & Social Service Providers | Counselor | Professional | 104100000X | S0013797 | OH | X | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.