Provider Demographics
NPI:1336686468
Name:KING, SHUNDRA MARIE (CDP)
Entity Type:Individual
Prefix:
First Name:SHUNDRA
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:CDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5019 GROVE ST # 103A
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4487
Mailing Address - Country:US
Mailing Address - Phone:206-407-3333
Mailing Address - Fax:
Practice Address - Street 1:3629 S D ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418
Practice Address - Country:US
Practice Address - Phone:253-769-3591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-26
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60535562101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)