Basic Information
| Provider Information | |||||||||
| NPI: | 1922352442 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | JEAN | ||||||||
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| Credential: | LMFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1812 N CAPITOL AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179628613 | ||||||||
| FaxNumber: | 3179625961 | ||||||||
| Practice Location | |||||||||
| Address1: | 1812 N CAPITOL AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179628613 | ||||||||
| FaxNumber: | 3179625961 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2012 | ||||||||
| LastUpdateDate: | 11/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 85000114A | IN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.