Provider Demographics
NPI:1104422070
Name:SUSAN L. KING
Entity type:Organization
Organization Name:SUSAN L. KING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LESLEY
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:949-584-7554
Mailing Address - Street 1:1560 SEMINOLE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-6536
Mailing Address - Country:US
Mailing Address - Phone:949-584-7554
Mailing Address - Fax:
Practice Address - Street 1:1601 GALBRAITH AVE SE STE 304
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-6479
Practice Address - Country:US
Practice Address - Phone:616-953-0544
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty