Provider Demographics
NPI:1336686062
Name:DEMETRIUS KING
Entity Type:Organization
Organization Name:DEMETRIUS KING
Other - Org Name:ASSUREDLINK CASE MANAGEMENT
Other - Org Type:Other Name
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:270-303-4669
Mailing Address - Street 1:1990 LOUISVILLE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1202
Mailing Address - Country:US
Mailing Address - Phone:270-303-4669
Mailing Address - Fax:
Practice Address - Street 1:1990 LOUISVILLE RD STE 101
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1202
Practice Address - Country:US
Practice Address - Phone:270-303-4669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASSUREDLINK CASE MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-19
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171431101YP2500X, 302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1336686062Medicaid
KY1205267671Medicaid