Provider Demographics
NPI:1326441957
Name:KING, ANDREA LEE
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LEE
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 COUNTY ROAD 5
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-9395
Mailing Address - Country:US
Mailing Address - Phone:419-674-3158
Mailing Address - Fax:
Practice Address - Street 1:222 W CARROL ST
Practice Address - Street 2:
Practice Address - City:KENTON
Practice Address - State:OH
Practice Address - Zip Code:43326-1202
Practice Address - Country:US
Practice Address - Phone:419-673-0775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOS1013588103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool