Healthcare Provider Details

I. General information

NPI: 1558547729
Provider Name (Legal Business Name): OMETRIS ELAINE KING DOCTORATE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: OMETRIS E KING DOCTORATE

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 W NORTHERN AVE STE 101
PHOENIX AZ
85021-5400
US

IV. Provider business mailing address

5045 W BASELINE RD # 105-179
LAVEEN AZ
85339-7392
US

V. Phone/Fax

Practice location:
  • Phone: 602-736-9647
  • Fax:
Mailing address:
  • Phone: 602-739-9647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number11910
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: