MEDICARE: VANESSA RAE KING LPC-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	63097	TX

General Provider Information

NPI Number	:	1003586413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VANESSA RAE KING LPC-S

Provider Business Mailing Address
First Line	:	12110 LITTLE SORREL TRL
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-4269
Country	:	US
Telephone Number	:	325-262-1982
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 EXECUTIVE DR
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-6801
Country	:	US
Telephone Number	:	325-262-1982
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2021
Last Update Date	:	09/16/2021

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