Provider Demographics
NPI:1134208812
Name:KING, KEVIN ROBERT (LCSW-R)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:ROBERT
Last Name:KING
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7486 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9450
Mailing Address - Country:US
Mailing Address - Phone:315-435-7703
Mailing Address - Fax:315-435-7715
Practice Address - Street 1:520 CEDAR ST
Practice Address - Street 2:OCDMH DAY TREATMENT PROGRAM FOR CHILDREN
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2302
Practice Address - Country:US
Practice Address - Phone:315-435-7703
Practice Address - Fax:315-435-7715
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR038655-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical