Provider Demographics
NPI:1356369987
Name:KING, ALAN RUSSELL (PHD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:RUSSELL
Last Name:KING
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58203-2945
Mailing Address - Country:US
Mailing Address - Phone:701-795-9113
Mailing Address - Fax:
Practice Address - Street 1:2100 S. COLUMBIA ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5895
Practice Address - Country:US
Practice Address - Phone:701-772-1588
Practice Address - Fax:701-746-6077
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND184103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16995Medicaid
ND16995Medicaid