Provider Demographics
NPI:1801104336
Name:KING, MICHAEL (MA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:657 E COTTONWOOD ST
Mailing Address - Street 2:SUITE 5C
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4407
Mailing Address - Country:US
Mailing Address - Phone:928-254-9455
Mailing Address - Fax:
Practice Address - Street 1:657 E COTTONWOOD ST
Practice Address - Street 2:SUITE 5C
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4407
Practice Address - Country:US
Practice Address - Phone:928-254-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC10980101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional