Basic Information
| Provider Information | |||||||||
| NPI: | 1356721260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONUCCI | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HINES | ||||||||
| OtherFirstName: | AMBER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 995 DAY HILL RD | ||||||||
| Address2: | |||||||||
| City: | WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060951722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607315522 | ||||||||
| FaxNumber: | 8607315536 | ||||||||
| Practice Location | |||||||||
| Address1: | 153 HAZARD AVE | ||||||||
| Address2: | |||||||||
| City: | ENFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060824592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602535020 | ||||||||
| FaxNumber: | 8602535030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2015 | ||||||||
| LastUpdateDate: | 01/04/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.