=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346849791
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW KING PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2020
-----------------------------------------------------
Last Update Date | 10/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 GALEN DR STE 4
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61821-7050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-714-7042
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 W WASHINGTON ST APT 103
-----------------------------------------------------
City | CHAMPAIGN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61820-4050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-743-9740
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 20043313B
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------