Provider Demographics
NPI:1558547729
Name:KING, OMETRIS ELAINE (MASTER OF ARTS)
Entity Type:Individual
Prefix:
First Name:OMETRIS
Middle Name:ELAINE
Last Name:KING
Suffix:
Gender:F
Credentials:MASTER OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 E FLINT ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-5472
Mailing Address - Country:US
Mailing Address - Phone:480-233-8654
Mailing Address - Fax:480-821-2888
Practice Address - Street 1:2210 W SOUTHERN AVE
Practice Address - Street 2:#C-11
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4714
Practice Address - Country:US
Practice Address - Phone:480-233-8654
Practice Address - Fax:480-821-2888
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11910101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional