Provider Demographics
NPI:1386194884
Name:KING, MAX I (LCDCIII)
Entity type:Individual
Prefix:MR
First Name:MAX
Middle Name:
Last Name:KING
Suffix:I
Gender:M
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-1849
Mailing Address - Country:US
Mailing Address - Phone:419-626-5623
Mailing Address - Fax:419-626-8778
Practice Address - Street 1:420 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-1849
Practice Address - Country:US
Practice Address - Phone:419-626-5623
Practice Address - Fax:419-626-8778
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-07
Last Update Date:2025-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.162552101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0281437Medicaid