Provider Demographics
NPI:1902953961
Name:KING, PAMELA DAWN (LCSW)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DAWN
Last Name:KING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 LAZY R LN
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-1323
Mailing Address - Country:US
Mailing Address - Phone:719-570-9061
Mailing Address - Fax:
Practice Address - Street 1:1401 W COLORADO AVE
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80904-4024
Practice Address - Country:US
Practice Address - Phone:719-442-1954
Practice Address - Fax:719-575-9683
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9898691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO077298Medicaid