Provider Demographics
NPI:1497492854
Name:ANTIN, KATHRYN ELIZABETH (LPC-S, CEDS-S)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ELIZABETH
Last Name:ANTIN
Suffix:
Gender:F
Credentials:LPC-S, CEDS-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4282 W CONEFLOWER PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6382
Mailing Address - Country:US
Mailing Address - Phone:479-790-9544
Mailing Address - Fax:
Practice Address - Street 1:19 E MOUNTAIN ST STE 13
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-6067
Practice Address - Country:US
Practice Address - Phone:479-309-3986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86036101YP2500X
ARP1410083101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional