Basic Information
| Provider Information | |||||||||
| NPI: | 1912034349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | GAIL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MS, LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GROSS | ||||||||
| OtherFirstName: | VIVIAN | ||||||||
| OtherMiddleName: | GAIL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 318 MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045190503 | ||||||||
| FaxNumber: | 3049275201 | ||||||||
| Practice Location | |||||||||
| Address1: | 318 MARKET STREET | ||||||||
| Address2: | |||||||||
| City: | SPENCER | ||||||||
| State: | WV | ||||||||
| PostalCode: | 252766906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045190503 | ||||||||
| FaxNumber: | 3049275201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2007 | ||||||||
| LastUpdateDate: | 12/28/2012 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1069 | WV | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | 1069 | WV | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.