Provider Demographics
NPI:1215289970
Name:KING, DESIREE LORRAINE (PSYD)
Entity type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:LORRAINE
Last Name:KING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 CREEK BLUFF WAY
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1821 BUSINESS PARK BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1230
Practice Address - Country:US
Practice Address - Phone:386-366-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-04
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9986103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300881Medicaid