MEDICARE: MARIBETH - KING MS

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	103TC1900X	Counseling Psychologist	01479	MO

General Provider Information

NPI Number	:	1770654881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIBETH - KING MS

Provider Business Mailing Address
First Line	:	134 WESTWOODS DR
Second Line	:	SEAPORT
City	:	LIBERTY
State	:	MO
Zip	:	64068-1181
Country	:	US
Telephone Number	:	816-792-3363
Fax Number	:	816-228-4943

Provider Business Practice Location Address
First Line	:	134 WESTWOODS DR
Second Line	:	SEAPORT
City	:	LIBERTY
State	:	MO
Zip	:	64068-1181
Country	:	US
Telephone Number	:	816-792-3363
Fax Number	:	816-228-4943

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

Provider Enumeration Date	:	11/11/2006
Last Update Date	:	07/08/2007

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