Provider Demographics
NPI:1134290521
Name:ANTZ, PHILIP JOACHIM (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JOACHIM
Last Name:ANTZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 STARLIGHT DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-1221
Mailing Address - Country:US
Mailing Address - Phone:631-345-6310
Mailing Address - Fax:631-775-6601
Practice Address - Street 1:470 STARLIGHT DR
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-1221
Practice Address - Country:US
Practice Address - Phone:631-345-6310
Practice Address - Fax:631-775-6601
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-040389-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN4K901Medicare ID - Type Unspecified
NYP08763Medicare UPIN