MEDICARE: KING PSYCHOLOGICAL SERVICES

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	251S00000X	Community/Behavioral Health Agency	1466-057	WI

General Provider Information

NPI Number	:	1174781298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KING PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	125 N ANDREWS ST
Second Line	:
City	:	SHAWANO
State	:	WI
Zip	:	54166-2441
Country	:	US
Telephone Number	:	715-524-5355
Fax Number	:

Provider Business Practice Location Address
First Line	:	1488 E GREEN BAY ST
Second Line	:
City	:	SHAWANO
State	:	WI
Zip	:	54166-2258
Country	:	US
Telephone Number	:	715-524-5355
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST/OWNER
Name	:	DR. SANDRA L. KING
Credential	:	PH.D.
Telephone Number	:	715-524-5355

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	05/27/2008

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