=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215445408
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER MARIE KING LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2018
-----------------------------------------------------
Last Update Date | 07/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5647 MAYBERRY SQ E
-----------------------------------------------------
City | SYLVANIA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43560-9456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-482-8277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 LEHMAN AVE STE 12
-----------------------------------------------------
City | BOWLING GREEN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43402-3087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | C.1901616
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------