Provider Demographics
NPI:1366494924
Name:KING, WANETTA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:WANETTA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15301 WARREN SHINGLE RD
Mailing Address - Street 2:
Mailing Address - City:BEALE AFB
Mailing Address - State:CA
Mailing Address - Zip Code:95903-1907
Mailing Address - Country:US
Mailing Address - Phone:530-634-3423
Mailing Address - Fax:530-634-0670
Practice Address - Street 1:15301 WARREN SHINGLE RD
Practice Address - Street 2:
Practice Address - City:BEALE AFB
Practice Address - State:CA
Practice Address - Zip Code:95903-1907
Practice Address - Country:US
Practice Address - Phone:530-634-3423
Practice Address - Fax:530-634-0670
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2552-C171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider