Provider Demographics
NPI:1093255499
Name:KING, DEMETRIUS (LPCC)
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 LOUISVILLE RD
Mailing Address - Street 2:STE. 101
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1202
Mailing Address - Country:US
Mailing Address - Phone:270-599-0212
Mailing Address - Fax:
Practice Address - Street 1:1990 LOUISVILLE RD
Practice Address - Street 2:STE. 101
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1202
Practice Address - Country:US
Practice Address - Phone:270-599-0212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-03
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171431101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1336686062Medicaid