Provider Demographics
NPI:1003314139
Name:KING, LIBBY JASMINE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LIBBY
Middle Name:JASMINE
Last Name:KING
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 NEWFOUND HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32952-2655
Mailing Address - Country:US
Mailing Address - Phone:321-427-7373
Mailing Address - Fax:
Practice Address - Street 1:6550 N WICKHAM RD STE 8
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2038
Practice Address - Country:US
Practice Address - Phone:321-427-7373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA17060235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023749900Medicaid