Provider Demographics
NPI:1750144663
Name:ANTI, ROSS (MSTOM, LAC)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:ANTI
Suffix:
Gender:M
Credentials:MSTOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:239 BANKER ST APT 4P
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-2687
Mailing Address - Country:US
Mailing Address - Phone:781-413-7834
Mailing Address - Fax:
Practice Address - Street 1:256 WEST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-2014
Practice Address - Country:US
Practice Address - Phone:212-431-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
NY007222171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No171400000XOther Service ProvidersHealth & Wellness Coach