Provider Demographics
NPI:1114637048
Name:KING, MALACHI (LSAA,CPSW)
Entity Type:Individual
Prefix:
First Name:MALACHI
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:LSAA,CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7384 VISTA DE SOBRE DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88012-0773
Mailing Address - Country:US
Mailing Address - Phone:575-202-6134
Mailing Address - Fax:
Practice Address - Street 1:7384 VISTA DE SOBRE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-0773
Practice Address - Country:US
Practice Address - Phone:575-202-6134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0702101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)