Provider Demographics
NPI:1649778184
Name:KING, LORETTA L (LBSW)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:L
Last Name:KING
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:LORETTA
Other - Middle Name:LUCILLE
Other - Last Name:KUEHLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBSW
Mailing Address - Street 1:315 E CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:HOBBS
Mailing Address - State:NM
Mailing Address - Zip Code:88240-8238
Mailing Address - Country:US
Mailing Address - Phone:575-393-0755
Mailing Address - Fax:575-393-0249
Practice Address - Street 1:315 E CLINTON ST
Practice Address - Street 2:
Practice Address - City:HOBBS
Practice Address - State:NM
Practice Address - Zip Code:88240-8238
Practice Address - Country:US
Practice Address - Phone:575-393-0755
Practice Address - Fax:575-393-0249
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMB-21781041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM12702218Medicaid