Provider Demographics
NPI:1245691997
Name:KING, LETRILLA C (EDD)
Entity type:Individual
Prefix:
First Name:LETRILLA
Middle Name:C
Last Name:KING
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 5TH AVE. STE. 100
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101
Mailing Address - Country:US
Mailing Address - Phone:619-865-0988
Mailing Address - Fax:619-456-0988
Practice Address - Street 1:1501 5TH AVE. STE. 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101
Practice Address - Country:US
Practice Address - Phone:619-865-0988
Practice Address - Fax:619-456-0988
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA31495103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)