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General NPI Number Information
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NPI Number | 1508409715
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Entity Type | Individual
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Provider Name | SUSAN LESLEY KING LMFT
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Gender | Female
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Dates
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Enumeration Date | 10/21/2019
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Last Update Date | 01/04/2021
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Provider Practice Location Address
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Address Line | 1601 GALBRAITH AVE SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-6479
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Country | US
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Telephone | 616-953-0544
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Fax |
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Provider Business Mailing Address
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Address Line | 1560 SEMINOLE RD SE
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City | GRAND RAPIDS
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State | MI
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Zip | 49506-6536
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Country | US
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Telephone | 949-584-7554
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 35001905A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 4101006694
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License Number State | MI
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