Provider Demographics
NPI:1720358807
Name:BOSTON, ANTONIO T (SAC-IT)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:T
Last Name:BOSTON
Suffix:
Gender:M
Credentials:SAC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 N 4TH ST STE 139
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2362
Mailing Address - Country:US
Mailing Address - Phone:414-264-4217
Mailing Address - Fax:414-264-4218
Practice Address - Street 1:2821 N 4TH ST STE 139
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2362
Practice Address - Country:US
Practice Address - Phone:414-264-4217
Practice Address - Fax:414-264-4218
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16231-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)