Provider Demographics
NPI:1871745687
Name:KING, ANGELA D (PSYD, LP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:D
Last Name:KING
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:D
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PLP
Mailing Address - Street 1:1800 COMMUNITY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-8804
Mailing Address - Country:US
Mailing Address - Phone:660-885-8131
Mailing Address - Fax:
Practice Address - Street 1:2108 W VISTA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5918
Practice Address - Country:US
Practice Address - Phone:417-597-4309
Practice Address - Fax:417-763-3308
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009030873103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499124600Medicaid