Provider Demographics
NPI:1356616908
Name:KING, DEIDRA MARIE (MA, MS, BCBA)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:MA, MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19019 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3253
Mailing Address - Country:US
Mailing Address - Phone:818-345-2345
Mailing Address - Fax:866-587-2383
Practice Address - Street 1:1890 PALMER AVE
Practice Address - Street 2:SUITE 404
Practice Address - City:LARCHMONT
Practice Address - State:NY
Practice Address - Zip Code:10538-3059
Practice Address - Country:US
Practice Address - Phone:914-833-1303
Practice Address - Fax:914-833-1305
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-11-8217103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst