Provider Demographics
NPI:1730513409
Name:ANTONACCI, KOLLEEN A (LCPC)
Entity type:Individual
Prefix:
First Name:KOLLEEN
Middle Name:A
Last Name:ANTONACCI
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:A
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2015 W MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-2073
Mailing Address - Country:US
Mailing Address - Phone:618-457-4044
Mailing Address - Fax:618-529-3834
Practice Address - Street 1:2015 W MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-2073
Practice Address - Country:US
Practice Address - Phone:618-457-4044
Practice Address - Fax:618-529-3834
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008168101Y00000X
ILCADC 2699101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor