Provider Demographics
NPI:1144556218
Name:AUGUSTINE, ANTHONY (LADC)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:AUGUSTINE
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 MIDDLESEX TPKE
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1317
Mailing Address - Country:US
Mailing Address - Phone:860-395-0111
Mailing Address - Fax:860-395-1264
Practice Address - Street 1:841 MIDDLESEX TPKE
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1317
Practice Address - Country:US
Practice Address - Phone:860-395-0111
Practice Address - Fax:860-395-1264
Is Sole Proprietor?:No
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000884101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)