Provider Demographics
NPI:1033504626
Name:KING, SAMANTHA (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S ARCADIAN WAY
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9220
Mailing Address - Country:US
Mailing Address - Phone:704-477-5212
Mailing Address - Fax:
Practice Address - Street 1:18515 STATESVILLE RD STE C1
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-5700
Practice Address - Country:US
Practice Address - Phone:704-641-3739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-01
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8344101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13856685OtherCAQH