Provider Demographics
NPI:1265531966
Name:KING, SALLY (PHD)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1898 CALHOUN ST
Mailing Address - Street 2:UNIT # 5
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2612
Mailing Address - Country:US
Mailing Address - Phone:803-252-5300
Mailing Address - Fax:
Practice Address - Street 1:1898 CALHOUN ST
Practice Address - Street 2:UNIT # 5
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2612
Practice Address - Country:US
Practice Address - Phone:803-252-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC217103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0075Medicaid
SC217OtherPSYCHOLOGIST LICENSE