Provider Demographics
NPI:1548536634
Name:KING, INDIA CHEATHAM (PSYD)
Entity type:Individual
Prefix:MS
First Name:INDIA
Middle Name:CHEATHAM
Last Name:KING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:INDIA
Other - Middle Name:MARIE ELSIE
Other - Last Name:CHEATHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:215 E HAWAII AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6011
Practice Address - Country:US
Practice Address - Phone:208-514-2529
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDPSY202839103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1548536634Medicaid