Provider Demographics
NPI:1558803783
Name:HARVEY, ANTOINETTE
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:HARVEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:701 W LAMM RD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:IL
Mailing Address - Zip Code:61032-9630
Mailing Address - Country:US
Mailing Address - Phone:815-233-6162
Mailing Address - Fax:
Practice Address - Street 1:701 W LAMM RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9630
Practice Address - Country:US
Practice Address - Phone:815-233-6162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-1372148Medicaid