Provider Demographics
NPI:1073797361
Name:KING, KERRY B
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:B
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 578
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-0578
Mailing Address - Country:US
Mailing Address - Phone:304-843-4400
Mailing Address - Fax:304-843-4409
Practice Address - Street 1:2700 4TH ST
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-1809
Practice Address - Country:US
Practice Address - Phone:304-843-4400
Practice Address - Fax:304-843-4409
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3675235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0152373000Medicaid