Basic Information
| Provider Information | |||||||||
| NPI: | 1013249374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONVICH | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | COLASANTE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2123 WILLOWLAKE DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770776023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812939499 | ||||||||
| FaxNumber: | 2812939499 | ||||||||
| Practice Location | |||||||||
| Address1: | 9525 KATY FWY | ||||||||
| Address2: | SUITE 312 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770241407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134639449 | ||||||||
| FaxNumber: | 7134637181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2010 | ||||||||
| LastUpdateDate: | 02/10/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 63670 | TX | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.