Provider Demographics
NPI:1346450806
Name:HETHERINGTON, ANTOINETTE C (CAC II)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:C
Last Name:HETHERINGTON
Suffix:
Gender:F
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2457 HEMPSTEAD RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-3411
Mailing Address - Country:US
Mailing Address - Phone:247-334-5223
Mailing Address - Fax:248-334-5223
Practice Address - Street 1:2457 HEMPSTEAD RD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-3411
Practice Address - Country:US
Practice Address - Phone:247-334-5223
Practice Address - Fax:248-334-5223
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2-00170101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200170OtherC ACII