Provider Demographics
NPI:1184040677
Name:KING, TINA (LAC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E HAWTHORN PKWY
Mailing Address - Street 2:SUITE 235
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1463
Mailing Address - Country:US
Mailing Address - Phone:847-868-3435
Mailing Address - Fax:
Practice Address - Street 1:117 STATE ROUTE 35 STE 2
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1886
Practice Address - Country:US
Practice Address - Phone:732-982-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-09
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00052000101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor