Provider Demographics
NPI:1609953835
Name:KING, PHYLLIS W (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:W
Last Name:KING
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 AGAWAM RD
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1303
Mailing Address - Country:US
Mailing Address - Phone:617-244-3806
Mailing Address - Fax:617-244-3199
Practice Address - Street 1:219 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WELLESLEY HILLS
Practice Address - State:MA
Practice Address - Zip Code:02481-3105
Practice Address - Country:US
Practice Address - Phone:617-244-3199
Practice Address - Fax:617-244-3199
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3201201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1858416Medicaid
MA1858416Medicaid