Provider Demographics
NPI:1528417284
Name:KING, PHILLIP JR
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:KING
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 LAMOUR LN
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-9616
Mailing Address - Country:US
Mailing Address - Phone:386-264-9499
Mailing Address - Fax:
Practice Address - Street 1:31 LAMOUR LN
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-9616
Practice Address - Country:US
Practice Address - Phone:386-264-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst