Provider Demographics
NPI:1225792427
Name:ANTWINE, DAMIEN (NCSP)
Entity Type:Individual
Prefix:
First Name:DAMIEN
Middle Name:
Last Name:ANTWINE
Suffix:
Gender:M
Credentials:NCSP
Other - Prefix:
Other - First Name:DAMIEN
Other - Middle Name:
Other - Last Name:ANTWINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NCSP
Mailing Address - Street 1:1686 ROSE CIR
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-4891
Mailing Address - Country:US
Mailing Address - Phone:630-864-0704
Mailing Address - Fax:
Practice Address - Street 1:402 RICHARDS ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60433-2218
Practice Address - Country:US
Practice Address - Phone:815-727-5271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1185755103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6099042Medicaid
IL1185755Medicaid
AZ63445Medicaid