Provider Demographics
NPI:1013685338
Name:KING, MIA NICOLE
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:NICOLE
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 STAGECOACH TRL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7960
Mailing Address - Country:US
Mailing Address - Phone:918-237-1760
Mailing Address - Fax:
Practice Address - Street 1:310 NE 28TH ST STE 204
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2837
Practice Address - Country:US
Practice Address - Phone:405-601-4565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist