Provider Demographics
NPI:1003244476
Name:ANTONIAZZI, AMY (LCSW-R)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:ANTONIAZZI
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 MICHAEL WILLIAM RD
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-2523
Mailing Address - Country:US
Mailing Address - Phone:516-378-3115
Mailing Address - Fax:
Practice Address - Street 1:1709 MICHAEL WILLIAM RD
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-2523
Practice Address - Country:US
Practice Address - Phone:516-378-3115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR040238104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker