Provider Demographics
NPI:1740053107
Name:KING, MARNEISHA Y
Entity type:Individual
Prefix:
First Name:MARNEISHA
Middle Name:Y
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11747 N 19TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85029-3590
Mailing Address - Country:US
Mailing Address - Phone:602-341-6403
Mailing Address - Fax:
Practice Address - Street 1:11747 N 19TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85029-3590
Practice Address - Country:US
Practice Address - Phone:602-341-6403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician