Provider Demographics
NPI:1619722436
Name:KING, KWAMAYNE D
Entity Type:Individual
Prefix:
First Name:KWAMAYNE
Middle Name:D
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2727 FIELDCREST DR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-5401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2727 FIELDCREST DR
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-5401
Practice Address - Country:US
Practice Address - Phone:224-535-1983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health