Provider Demographics
NPI:1437760493
Name:ANTENUCCI, LAURA MARIA (LSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIA
Last Name:ANTENUCCI
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 N COURT ST STE 11
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-1766
Mailing Address - Country:US
Mailing Address - Phone:330-647-1076
Mailing Address - Fax:
Practice Address - Street 1:799 N COURT ST STE 11
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-1766
Practice Address - Country:US
Practice Address - Phone:330-636-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OHS.20053241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No175T00000XOther Service ProvidersPeer Specialist