Provider Demographics
NPI:1710078217
Name:KING, CAROLYN MARY (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARY
Last Name:KING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 NE LOOP 410
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1625
Mailing Address - Country:US
Mailing Address - Phone:210-829-0134
Mailing Address - Fax:210-804-1887
Practice Address - Street 1:1635 NE LOOP 410
Practice Address - Street 2:SUITE 901
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1625
Practice Address - Country:US
Practice Address - Phone:210-829-0134
Practice Address - Fax:210-804-1887
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX116991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00S89PMedicare ID - Type Unspecified