Provider Demographics
NPI:1962679688
Name:KING, THEODORA (MFT INTERN)
Entity Type:Individual
Prefix:MS
First Name:THEODORA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47825 OASIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-6950
Mailing Address - Country:US
Mailing Address - Phone:760-863-8544
Mailing Address - Fax:760-863-8587
Practice Address - Street 1:47825 OASIS ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6950
Practice Address - Country:US
Practice Address - Phone:760-863-8544
Practice Address - Fax:760-863-8587
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CAAMFT106002106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner