Provider Demographics
NPI:1750722286
Name:THACKER, ANTOINETTE M (LISW-S)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:M
Last Name:THACKER
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8778 COTTONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45231-4706
Mailing Address - Country:US
Mailing Address - Phone:513-305-2218
Mailing Address - Fax:513-737-4603
Practice Address - Street 1:1910 FAIRGROVE AVE STE E
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-1930
Practice Address - Country:US
Practice Address - Phone:513-795-7557
Practice Address - Fax:513-737-4603
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-12
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.1000009-SUPV1041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical