Provider Demographics
NPI:1538512025
Name:KING, TRISTRAM (LMFT)
Entity Type:Individual
Prefix:
First Name:TRISTRAM
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 SUNNYGLEN DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-7553
Mailing Address - Country:US
Mailing Address - Phone:925-389-3993
Mailing Address - Fax:707-649-4086
Practice Address - Street 1:157 SUNNYGLEN DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94591-7553
Practice Address - Country:US
Practice Address - Phone:925-389-3993
Practice Address - Fax:707-649-4086
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93998106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist