Provider Demographics
NPI:1003586413
Name:KING, VANESSA RAE (LPC-S)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:RAE
Last Name:KING
Suffix:
Gender:F
Credentials:LPC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 LITTLE SORREL TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-4269
Mailing Address - Country:US
Mailing Address - Phone:325-262-1982
Mailing Address - Fax:
Practice Address - Street 1:3131 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6801
Practice Address - Country:US
Practice Address - Phone:325-262-1982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63097101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional