Provider Demographics
NPI:1487296687
Name:KING, MICHELLE LYNN (LMSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYNN
Last Name:KING
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:LYNN
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:303 ROBY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1800
Mailing Address - Country:US
Mailing Address - Phone:315-434-3805
Mailing Address - Fax:315-434-3820
Practice Address - Street 1:303 ROBY AVE
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-1800
Practice Address - Country:US
Practice Address - Phone:315-434-3805
Practice Address - Fax:315-434-3820
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0623061041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool