Provider Demographics
NPI:1235705757
Name:WOLLERT, ANTONIA (LPC)
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:WOLLERT
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:ANTONIA
Other - Middle Name:DEL CARMEN
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:47-515 WAIPUA PL
Mailing Address - Street 2:
Mailing Address - City:KANEOHE
Mailing Address - State:HI
Mailing Address - Zip Code:96744-5446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47-515 WAIPUA PL
Practice Address - Street 2:
Practice Address - City:KANEOHE
Practice Address - State:HI
Practice Address - Zip Code:96744-5446
Practice Address - Country:US
Practice Address - Phone:808-517-9670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2540101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor