Provider Demographics
NPI:1689979106
Name:KING, LATANYA (MASTERS MAED)
Entity Type:Individual
Prefix:MS
First Name:LATANYA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:MASTERS MAED
Other - Prefix:MS
Other - First Name:LA'TANYA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASTERS
Mailing Address - Street 1:1122 E BUCKEYE RD
Mailing Address - Street 2:6216 S. 36TH STREET
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-4020
Mailing Address - Country:US
Mailing Address - Phone:602-252-2241
Mailing Address - Fax:602-252-2482
Practice Address - Street 1:1122 EAST BUCKEYE ROAD
Practice Address - Street 2:SUITE B-1
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034
Practice Address - Country:US
Practice Address - Phone:602-252-2241
Practice Address - Fax:602-252-2482
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-13
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-0821101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)