Healthcare Provider Details

I. General information

NPI: 1376408690
Provider Name (Legal Business Name): THOMASA SHANNEL KING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2705 E 24TH ST # AT
KANSAS CITY MO
64127-4016
US

IV. Provider business mailing address

2705 E 24TH ST # AT
KANSAS CITY MO
64127-4016
US

V. Phone/Fax

Practice location:
  • Phone: 816-302-5622
  • Fax:
Mailing address:
  • Phone: 816-302-5622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT25-453608
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: