Provider Demographics
NPI:1205204401
Name:TRISTAN, ANTOINETTE (LMHC)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:TRISTAN
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 1:127 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5474
Mailing Address - Country:US
Mailing Address - Phone:607-273-7494
Mailing Address - Fax:
Practice Address - Street 1:127 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5474
Practice Address - Country:US
Practice Address - Phone:607-273-7494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-04
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1336163963Medicaid