Provider Demographics
NPI:1043229016
Name:ANTONICK, LISA ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:ANTONICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:ROSENFELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 LONGLEAF PL
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-8919
Mailing Address - Country:US
Mailing Address - Phone:518-669-1798
Mailing Address - Fax:
Practice Address - Street 1:105 LONGLEAF PL
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-8919
Practice Address - Country:US
Practice Address - Phone:518-669-1798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0065091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000403187001OtherBS NE NY
NCGROUP NUMBEROtherBLUE CROSS OF NORTH CAROLINA
248368OtherVALUE OPTIONS
NY02348474Medicaid
N7L561OtherEMPIRE
257617OtherCOM PSYCH
326051OtherMHN
537788000OtherMAGELLAN
NC6007404Medicaid
040426032094OtherFIDELIS
361170OtherMVP
NCGROUP NUMBEROtherBLUE CROSS OF NORTH CAROLINA
248368OtherVALUE OPTIONS