Healthcare Provider Details

I. General information

NPI: 1013093624
Provider Name (Legal Business Name): SUSAN R. KING PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 HEALTH CENTER BLVD
ESTERO FL
34135-8127
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-468-0300
  • Fax: 239-343-4257
Mailing address:
  • Phone: 239-343-6050
  • Fax: 239-343-6051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6846
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6846
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: