Provider Demographics
NPI:1477163699
Name:KING, TINA LOUISE (LCDCIII)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:LOUISE
Last Name:KING
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3793 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5705
Mailing Address - Country:US
Mailing Address - Phone:216-232-5302
Mailing Address - Fax:
Practice Address - Street 1:3793 GREEN RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5705
Practice Address - Country:US
Practice Address - Phone:216-232-5302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty