Provider Demographics
NPI:1083350904
Name:KING, BREANNA ANTIONETTE (LLMSW, BA)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:ANTIONETTE
Last Name:KING
Suffix:
Gender:F
Credentials:LLMSW, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 E ISABELLA RD
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-8344
Mailing Address - Country:US
Mailing Address - Phone:989-835-3466
Mailing Address - Fax:
Practice Address - Street 1:1213 E ISABELLA RD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-8344
Practice Address - Country:US
Practice Address - Phone:989-835-3466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-12
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68511154391041C0700X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical