Provider Demographics
NPI:1932223757
Name:KING, JUSTIN T (LCPC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:T
Last Name:KING
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 LENA LN
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21826-2034
Mailing Address - Country:US
Mailing Address - Phone:410-845-1092
Mailing Address - Fax:
Practice Address - Street 1:463 LENA LN
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:MD
Practice Address - Zip Code:21826-2034
Practice Address - Country:US
Practice Address - Phone:410-845-1092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC14056101YP2500X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD705371101Medicaid