Provider Demographics
NPI:1295754067
Name:ANTLE, CONNIE (LCSW)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:ANTLE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:
Other - Last Name:CARTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:130 SOUTHERN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-3223
Mailing Address - Country:US
Mailing Address - Phone:606-679-4782
Mailing Address - Fax:606-678-5296
Practice Address - Street 1:521 OLD HODGENVILLE RD
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:KY
Practice Address - Zip Code:42743-9493
Practice Address - Country:US
Practice Address - Phone:270-932-3226
Practice Address - Fax:270-932-5328
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical