Provider Demographics
NPI:1114977543
Name:KING, JOANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOANNE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 EAST MAIN STREET
Mailing Address - Street 2:PTSD CLINIC (116A)
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832
Mailing Address - Country:US
Mailing Address - Phone:217-554-4257
Mailing Address - Fax:217-554-4822
Practice Address - Street 1:1900 EAST MAIN STREET
Practice Address - Street 2:PTSD CLINIC (116A)
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-554-4257
Practice Address - Fax:217-554-4822
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040950103TC0700X
IN20040950A103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200177930Medicaid
IN200177930Medicaid