Healthcare Provider Details

I. General information

NPI: 1104695683
Provider Name (Legal Business Name): KING IYOBOSA WILLIAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15640 N 7TH ST STE A1
PHOENIX AZ
85022-3520
US

IV. Provider business mailing address

PO BOX 63811
PHOENIX AZ
85082-3811
US

V. Phone/Fax

Practice location:
  • Phone: 602-675-0864
  • Fax: 602-675-1839
Mailing address:
  • Phone: 480-579-6930
  • Fax: 602-675-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: