Provider Demographics
NPI:1043898083
Name:ANTON, STACEY MICHELLE (LMSW)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
Last Name:ANTON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98120 QUEENS BLVD STE 1C
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4414
Mailing Address - Country:US
Mailing Address - Phone:516-220-4530
Mailing Address - Fax:
Practice Address - Street 1:300 E 34TH ST APT 6A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4905
Practice Address - Country:US
Practice Address - Phone:631-874-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-31
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY107927104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker