Provider Demographics
NPI:1275561961
Name:KING, WALTER B (PSYD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:B
Last Name:KING
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 E ORMAN AVE
Mailing Address - Street 2:SUITE G12
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3537
Mailing Address - Country:US
Mailing Address - Phone:719-564-1800
Mailing Address - Fax:719-564-1865
Practice Address - Street 1:1925 E ORMAN AVE
Practice Address - Street 2:SUITE G12
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3537
Practice Address - Country:US
Practice Address - Phone:719-564-1800
Practice Address - Fax:719-564-1865
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO574103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO4703-9Medicare ID - Type Unspecified