=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245364256
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT GRANT KING LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 12TH AVE S SUITE 204
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-3952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-463-9450
-----------------------------------------------------
Fax | 208-465-9072
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 12TH AVE S STE 204
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83651-3952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-463-9450
-----------------------------------------------------
Fax | 208-465-9072
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCSW-24802
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------