Provider Demographics
NPI:1619356821
Name:KING, SHELLEY MARIE (LISW)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2285 BENDEN DR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2568
Mailing Address - Country:US
Mailing Address - Phone:330-264-9029
Mailing Address - Fax:
Practice Address - Street 1:2285 BENDEN DR
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2568
Practice Address - Country:US
Practice Address - Phone:330-264-9029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1601218104100000X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0300220Medicaid