Provider Demographics
NPI:1821782665
Name:ANTIGUA, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:ANTIGUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 W 157TH ST APT 52
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-7637
Mailing Address - Country:US
Mailing Address - Phone:347-883-0559
Mailing Address - Fax:
Practice Address - Street 1:3249 KINGSBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-5514
Practice Address - Country:US
Practice Address - Phone:718-926-9975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health