Provider Demographics
NPI:1790328144
Name:ANTONATOS, LYDIA ANGELICA (LMHC)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:ANGELICA
Last Name:ANTONATOS
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3732 COACHMAN LN SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-1335
Mailing Address - Country:US
Mailing Address - Phone:954-260-3979
Mailing Address - Fax:
Practice Address - Street 1:3732 COACHMAN LN SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-1335
Practice Address - Country:US
Practice Address - Phone:954-260-3979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-17
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17334101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health