Provider Demographics
NPI:1659452159
Name:KING, ELISABETH D (PSYD)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:D
Last Name:KING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 W MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-6116
Mailing Address - Country:US
Mailing Address - Phone:559-697-3264
Mailing Address - Fax:
Practice Address - Street 1:520 E TULARE AVE
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93292-3629
Practice Address - Country:US
Practice Address - Phone:559-623-0943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20259103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL202590Medicare ID - Type Unspecified