Provider Demographics
NPI:1699480814
Name:KING, CLYDE SHELLY (LPC)
Entity type:Individual
Prefix:
First Name:CLYDE
Middle Name:SHELLY
Last Name:KING
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2633 S BEULAH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-4514
Mailing Address - Country:US
Mailing Address - Phone:215-501-2612
Mailing Address - Fax:
Practice Address - Street 1:2633 S BEULAH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-4514
Practice Address - Country:US
Practice Address - Phone:215-501-2612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
PAPC014966101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty