Provider Demographics
NPI:1639709918
Name:KING, ANTONIO JR (LSATP)
Entity Type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:
Last Name:KING
Suffix:JR
Gender:M
Credentials:LSATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 MEADOWLAKE RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-3617
Mailing Address - Country:US
Mailing Address - Phone:757-713-0385
Mailing Address - Fax:
Practice Address - Street 1:519 XENIA AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45410-1823
Practice Address - Country:US
Practice Address - Phone:937-589-2277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000615101YA0400X
VA0710103027101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)