MEDICARE: LA DETRIA KING LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor	LPC006088	GA

General Provider Information

NPI Number	:	1144564303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LA DETRIA KING LPC

Provider Business Mailing Address
First Line	:	2918 HENRY ST
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-3848
Country	:	US
Telephone Number	:	706-832-6679
Fax Number	:

Provider Business Practice Location Address
First Line	:	2610 COMMONS BLVD
Second Line	:	SUITE B
City	:	AUGUSTA
State	:	GA
Zip	:	30909-2080
Country	:	US
Telephone Number	:	706-832-6679
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2012
Last Update Date	:	11/11/2012

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