Basic Information
| Provider Information | |||||||||
| NPI: | 1700955077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC0012 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2017 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850062102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024524684 | ||||||||
| FaxNumber: | 6023580399 | ||||||||
| Practice Location | |||||||||
| Address1: | 3306 W CATALINA DR | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850175291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023530703 | ||||||||
| FaxNumber: | 6023530715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LPC0012 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | LPC0012 | 01 | AZ | THERAPIST | OTHER |