Provider Demographics
NPI:1598025165
Name:KING, LOREN CARRILLO (PHD)
Entity Type:Individual
Prefix:
First Name:LOREN
Middle Name:CARRILLO
Last Name:KING
Suffix:
Gender:M
Credentials:PHD
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 90824
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92427-1824
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3102 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369-7813
Practice Address - Country:US
Practice Address - Phone:909-425-6417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24445103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical