Provider Demographics
NPI:1780969949
Name:KING, DARRELL G (MA, RN, CMHN)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:G
Last Name:KING
Suffix:
Gender:M
Credentials:MA, RN, CMHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3005
Mailing Address - Country:US
Mailing Address - Phone:585-241-1707
Mailing Address - Fax:585-241-1273
Practice Address - Street 1:1111 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3005
Practice Address - Country:US
Practice Address - Phone:585-241-1707
Practice Address - Fax:585-241-1273
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY604401101Y00000X, 163WP0808X
NY24330101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)