Provider Demographics
NPI:1184198665
Name:KING, MARY CATHERINE (MS, LPC-MHSP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:KING
Suffix:
Gender:F
Credentials:MS, LPC-MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7467 SWINNEA RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6009
Mailing Address - Country:US
Mailing Address - Phone:662-536-6210
Mailing Address - Fax:
Practice Address - Street 1:52 TIMBER CREEK DR STE 203
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-4388
Practice Address - Country:US
Practice Address - Phone:662-536-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4499101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional