Provider Demographics
NPI:1780712000
Name:KING, EDWARD CORNELIUS (LCSW)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:CORNELIUS
Last Name:KING
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4131 SPICEWOOD SPRINGS RD
Mailing Address - Street 2:SUITE Q-2
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8661
Mailing Address - Country:US
Mailing Address - Phone:512-338-4095
Mailing Address - Fax:512-338-4070
Practice Address - Street 1:4131 SPICEWOOD SPRINGS RD
Practice Address - Street 2:SUITE Q-2
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8661
Practice Address - Country:US
Practice Address - Phone:512-338-4095
Practice Address - Fax:512-338-4070
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX066281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX227440000OtherMAGELLAN BEHAVIORAL HEALT
TX00S83JOtherBLUE CROSS BLUE SHIELD
TX00S83JMedicare ID - Type Unspecified