Healthcare Provider Details

I. General information

NPI: 1629211396
Provider Name (Legal Business Name): DEANNA MARIE KING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2009
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 W REDONDO BEACH BLVD STE 300
GARDENA CA
90247-4175
US

IV. Provider business mailing address

1045 W REDONDO BEACH BLVD STE 300
GARDENA CA
90247-4175
US

V. Phone/Fax

Practice location:
  • Phone: 323-241-6730
  • Fax: 310-324-2111
Mailing address:
  • Phone: 323-241-6730
  • Fax: 310-324-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: