Provider Demographics
NPI:1376131946
Name:ANTON, IDANIA
Entity Type:Individual
Prefix:
First Name:IDANIA
Middle Name:
Last Name:ANTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-3920
Mailing Address - Country:US
Mailing Address - Phone:786-344-7830
Mailing Address - Fax:
Practice Address - Street 1:751 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:OPA LOCKA
Practice Address - State:FL
Practice Address - Zip Code:33054-3920
Practice Address - Country:US
Practice Address - Phone:786-344-7830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-08
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-123058106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty