Basic Information
| Provider Information | |||||||||
| NPI: | 1417250655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEANTONIO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1208 POINTE CENTRE DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374213983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238936500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1208 POINTE CENTRE DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374213983 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238936500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2010 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 5709 | TN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.