Provider Demographics
NPI:1386025807
Name:KING, KIMBERLY (LISW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15414 ROCKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3947
Mailing Address - Country:US
Mailing Address - Phone:240-447-0055
Mailing Address - Fax:
Practice Address - Street 1:398 W BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1369
Practice Address - Country:US
Practice Address - Phone:216-340-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OHI.15003371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health