Provider Demographics
NPI:1659623213
Name:KING, EDWARD CECIL (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:CECIL
Last Name:KING
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6112 PALMAS DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6751
Mailing Address - Country:US
Mailing Address - Phone:386-236-9271
Mailing Address - Fax:
Practice Address - Street 1:1690 DUNLAWTON AVE
Practice Address - Street 2:SUITE 125
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8979
Practice Address - Country:US
Practice Address - Phone:386-236-9271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL105201041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023145400Medicaid