Provider Demographics
NPI:1467122051
Name:ANTIDOTE RECOVERY LLC
Entity Type:Organization
Organization Name:ANTIDOTE RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:MIGUEL
Authorized Official - Last Name:MAGALLANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:812-624-1180
Mailing Address - Street 1:3310 E 10TH ST # 4-156
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-7285
Mailing Address - Country:US
Mailing Address - Phone:812-624-1180
Mailing Address - Fax:
Practice Address - Street 1:3310 E 10TH ST # 4-156
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-7285
Practice Address - Country:US
Practice Address - Phone:812-624-1180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-15
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty