Provider Demographics
NPI:1578969416
Name:LIDDY, ANTONETTE MARIE (MS LPC NCC)
Entity Type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:MARIE
Last Name:LIDDY
Suffix:
Gender:F
Credentials:MS LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2369 S 57TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2215
Mailing Address - Country:US
Mailing Address - Phone:414-321-4793
Mailing Address - Fax:
Practice Address - Street 1:800 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2634
Practice Address - Country:US
Practice Address - Phone:414-429-6522
Practice Address - Fax:414-502-0192
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI244-125101Y00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker