Provider Demographics
NPI:1902088719
Name:ANTOSZYK, NADIA CORINNE
Entity Type:Individual
Prefix:
First Name:NADIA
Middle Name:CORINNE
Last Name:ANTOSZYK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097 SARDIS COVE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2121
Mailing Address - Country:US
Mailing Address - Phone:704-516-4467
Mailing Address - Fax:
Practice Address - Street 1:769 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1118
Practice Address - Country:US
Practice Address - Phone:704-376-7180
Practice Address - Fax:704-531-9266
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0040211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106823Medicaid
NC2876032AMedicare PIN