Provider Demographics
NPI:1922754696
Name:ANTICO, JOSEPH TYLER (LCSW)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:TYLER
Last Name:ANTICO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:CO
Mailing Address - Zip Code:80420-0308
Mailing Address - Country:US
Mailing Address - Phone:404-922-1862
Mailing Address - Fax:
Practice Address - Street 1:998 BLUE RIVER PKWY
Practice Address - Street 2:
Practice Address - City:SILVERTHORNE
Practice Address - State:CO
Practice Address - Zip Code:80498-8958
Practice Address - Country:US
Practice Address - Phone:970-439-4714
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24395401101YS0200X
COCSW.099297131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool