Healthcare Provider Details

I. General information

NPI: 1578091252
Provider Name (Legal Business Name): MICHAEL KING LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 COVE RD
JASPER GA
30143-1356
US

IV. Provider business mailing address

201 COVE RD
JASPER GA
30143-1356
US

V. Phone/Fax

Practice location:
  • Phone: 706-253-9515
  • Fax: 706-253-9516
Mailing address:
  • Phone: 706-253-9515
  • Fax: 706-253-9516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006094
License Number StateGA

VIII. Authorized Official

Name: MICHAEL ESTEL KING
Title or Position: SOLE PROPRIETOR
Credential: LCSW
Phone: 706-669-3526