Basic Information
| Provider Information | |||||||||
| NPI: | 1962496067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KING | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.MIN LPC LCDC RSOTP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 MANTOOTH AVE | ||||||||
| Address2: | |||||||||
| City: | LUFKIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759043014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366394993 | ||||||||
| FaxNumber: | 9366396838 | ||||||||
| Practice Location | |||||||||
| Address1: | 459 W HOUSTON ST | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759513510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4093848060 | ||||||||
| FaxNumber: | 4093842340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 14256 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.