Healthcare Provider Details

I. General information

NPI: 1043695281
Provider Name (Legal Business Name): KIMBERLY KING LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY KING LSW

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 OAK ST.
BUENA VISTA CO
81211-8121
US

IV. Provider business mailing address

3225 INDEPENDENCE RD
CANON CITY CO
81212-9380
US

V. Phone/Fax

Practice location:
  • Phone: 719-539-6502
  • Fax:
Mailing address:
  • Phone: 719-275-2351
  • Fax: 719-269-9386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0009920632
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: