Healthcare Provider Details

I. General information

NPI: 1053256966
Provider Name (Legal Business Name): KRISTEN ASHLEY KING
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 FOUNTAINS PKWY # 201
FAIRVIEW HEIGHTS IL
62208-2170
US

IV. Provider business mailing address

632 ROYAL HEIGHTS RD
BELLEVILLE IL
62226-5905
US

V. Phone/Fax

Practice location:
  • Phone: 618-515-1441
  • Fax:
Mailing address:
  • Phone: 618-772-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: