Provider Demographics
NPI:1679458442
Name:KING, IMANI KHALI'AH
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:KHALI'AH
Last Name:KING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-5036
Mailing Address - Country:US
Mailing Address - Phone:743-999-3768
Mailing Address - Fax:336-293-4523
Practice Address - Street 1:905 FRIEDBERG CHURCH RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-9803
Practice Address - Country:US
Practice Address - Phone:336-251-1180
Practice Address - Fax:336-251-1181
Is Sole Proprietor?:No
Enumeration Date:2025-08-09
Last Update Date:2025-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician