Provider Demographics
NPI:1760146815
Name:ANTOLIN-WILCZEK, ELANA
Entity Type:Individual
Prefix:
First Name:ELANA
Middle Name:
Last Name:ANTOLIN-WILCZEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MERRYDALE RD APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4036
Mailing Address - Country:US
Mailing Address - Phone:805-452-8665
Mailing Address - Fax:
Practice Address - Street 1:2 PADRE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2114
Practice Address - Country:US
Practice Address - Phone:707-553-1784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst