Basic Information
| Provider Information | |||||||||
| NPI: | 1558803783 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARVEY | ||||||||
| FirstName: | ANTOINETTE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | ANTOINETTE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 701 W LAMM RD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610329630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152336162 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 701 W LAMM RD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610329630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8152336162 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2016 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 37-1372148 | 05 | IL | MEDICAID |