Healthcare Provider Details

I. General information

NPI: 1750629911
Provider Name (Legal Business Name): AMY KING LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2013
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 SE RIVIERA DR
BEND OR
97702-1814
US

IV. Provider business mailing address

PO BOX 8071
BEND OR
97708-8071
US

V. Phone/Fax

Practice location:
  • Phone: 541-350-2905
  • Fax:
Mailing address:
  • Phone: 541-350-2905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL3167
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: AMY KING
Title or Position: OWNER
Credential: LCSW
Phone: 541-350-2905