Provider Demographics
NPI:1710962683
Name:ANTIA, KERSEY H (PHD)
Entity Type:Individual
Prefix:DR
First Name:KERSEY
Middle Name:H
Last Name:ANTIA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8318 138TH PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-1746
Mailing Address - Country:US
Mailing Address - Phone:708-460-6060
Mailing Address - Fax:708-460-6060
Practice Address - Street 1:17716 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3936
Practice Address - Country:US
Practice Address - Phone:708-460-6060
Practice Address - Fax:708-460-6060
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S07215Medicare UPIN
743740Medicare ID - Type Unspecified