Provider Demographics
NPI:1093724114
Name:KING, KATHRYN A (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:KING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 SAGAMORE COVE RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-5020
Mailing Address - Country:US
Mailing Address - Phone:203-483-6096
Mailing Address - Fax:
Practice Address - Street 1:1078 MAIN ST UNIT 4
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3716
Practice Address - Country:US
Practice Address - Phone:203-483-6096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0031981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140003198CT03OtherANTHEM ID
CT10743398OtherC.A.Q.H. ID
CT800002805Medicare ID - Type UnspecifiedINDIVIDUAL ID