Provider Demographics
NPI:1578873113
Name:ANTALL, RICHARD JUSTIN (LISW-S)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:JUSTIN
Last Name:ANTALL
Suffix:
Gender:M
Credentials:LISW-S
Other - Prefix:
Other - First Name:R. JUSTIN
Other - Middle Name:
Other - Last Name:ANTALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW-S
Mailing Address - Street 1:384 SADDLER RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1118
Mailing Address - Country:US
Mailing Address - Phone:440-567-3063
Mailing Address - Fax:
Practice Address - Street 1:3737 LANDER ROAD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5712
Practice Address - Country:US
Practice Address - Phone:216-831-2255
Practice Address - Fax:216-378-3906
Is Sole Proprietor?:No
Enumeration Date:2010-10-18
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.08010901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid