Provider Demographics
NPI:1134751423
Name:ANTOLICK, MATTHEW P (LMHC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:ANTOLICK
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 S M ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-3708
Mailing Address - Country:US
Mailing Address - Phone:321-439-9348
Mailing Address - Fax:
Practice Address - Street 1:621 PACIFIC AVE STE 302
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4611
Practice Address - Country:US
Practice Address - Phone:321-439-9348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60900776101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health