Provider Demographics
NPI:1336136613
Name:KING, JOHN RANDOLPH (LISW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDOLPH
Last Name:KING
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 KLOTZ RD
Mailing Address - Street 2:P.O. BOX 738
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4820
Mailing Address - Country:US
Mailing Address - Phone:419-352-7588
Mailing Address - Fax:419-354-4977
Practice Address - Street 1:1045 KLOTZ RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4820
Practice Address - Country:US
Practice Address - Phone:419-352-7588
Practice Address - Fax:419-354-4977
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0004568104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker