Healthcare Provider Details

I. General information

NPI: 1336686062
Provider Name (Legal Business Name): DEMETRIUS KING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1990 LOUISVILLE RD STE 101
BOWLING GREEN KY
42101-1202
US

IV. Provider business mailing address

1990 LOUISVILLE RD STE 101
BOWLING GREEN KY
42101-1202
US

V. Phone/Fax

Practice location:
  • Phone: 270-303-4669
  • Fax:
Mailing address:
  • Phone: 270-303-4669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number171431
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number171431
License Number StateKY

VIII. Authorized Official

Name: DEMETRIUS KING
Title or Position: THERAPIST/OWNER
Credential: LPCC
Phone: 270-303-4669