Provider Demographics
NPI:1538752845
Name:KING, MICHELLE MARIE (RADT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:KING
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29858 MULEDEER LN
Mailing Address - Street 2:
Mailing Address - City:CASTAIC
Mailing Address - State:CA
Mailing Address - Zip Code:91384-3590
Mailing Address - Country:US
Mailing Address - Phone:716-523-5657
Mailing Address - Fax:
Practice Address - Street 1:20946 DEVONSHIRE ST # 100
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-8270
Practice Address - Country:US
Practice Address - Phone:716-523-5657
Practice Address - Fax:818-626-8415
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1408151020101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)