Provider Demographics
NPI:1104240126
Name:DELUCA, ANTONETTE
Entity type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:
Last Name:DELUCA
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 1:407 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-2442
Mailing Address - Country:US
Mailing Address - Phone:419-984-1312
Mailing Address - Fax:419-626-9435
Practice Address - Street 1:407 DECATUR ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-2442
Practice Address - Country:US
Practice Address - Phone:419-984-1312
Practice Address - Fax:419-626-9435
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-11
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS00127441041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS0012744Medicaid