Provider Demographics
NPI:1184182719
Name:CLINKSCALES, ANTONIO O'NEIL
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:O'NEIL
Last Name:CLINKSCALES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SURREY DR
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-1035
Mailing Address - Country:US
Mailing Address - Phone:804-994-7998
Mailing Address - Fax:
Practice Address - Street 1:103 SURREY DR
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-1035
Practice Address - Country:US
Practice Address - Phone:804-994-7998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-02
Last Update Date:2019-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA81-5150005Medicaid