Provider Demographics
NPI:1578117206
Name:KING, SUSANNA JOY
Entity Type:Individual
Prefix:MRS
First Name:SUSANNA
Middle Name:JOY
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-0215
Mailing Address - Country:US
Mailing Address - Phone:423-506-0038
Mailing Address - Fax:
Practice Address - Street 1:4160 OCOEE ST N STE 8
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4886
Practice Address - Country:US
Practice Address - Phone:423-464-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker