Provider Demographics
NPI:1982278073
Name:KING, MARK ANTHONY (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:KING
Suffix:
Gender:M
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 PROTZMAN ST APT 201
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-7519
Mailing Address - Country:US
Mailing Address - Phone:304-322-0267
Mailing Address - Fax:
Practice Address - Street 1:207 FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-2710
Practice Address - Country:US
Practice Address - Phone:681-404-6869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVBP00944913104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker