Provider Demographics
NPI:1871152140
Name:KING, MATTHEW (MAC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12166 OLD BIG BEND RD STE 204
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6836
Mailing Address - Country:US
Mailing Address - Phone:314-822-8888
Mailing Address - Fax:
Practice Address - Street 1:12166 OLD BIG BEND RD STE 204
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6836
Practice Address - Country:US
Practice Address - Phone:314-822-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional