Provider Demographics
NPI:1093182354
Name:KING, RONALD
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22100 VICTORY BLVD
Mailing Address - Street 2:#D218
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-1944
Mailing Address - Country:US
Mailing Address - Phone:818-584-4749
Mailing Address - Fax:
Practice Address - Street 1:6501 VAN NUYS BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1425
Practice Address - Country:US
Practice Address - Phone:818-902-5315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health