Provider Demographics
NPI:1245695717
Name:WALCOTT, ANTONIO DELANO JR (MHC-LP)
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:DELANO
Last Name:WALCOTT
Suffix:JR
Gender:M
Credentials:MHC-LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DOVER PL
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-2220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2706
Practice Address - Country:US
Practice Address - Phone:631-369-0104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health