Provider Demographics
NPI:1104354307
Name:ANTONIADOU, RAFAELA
Entity type:Individual
Prefix:
First Name:RAFAELA
Middle Name:
Last Name:ANTONIADOU
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31745 E DITNER DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48173-1014
Mailing Address - Country:US
Mailing Address - Phone:313-723-3609
Mailing Address - Fax:
Practice Address - Street 1:31745 E DITNER DR
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:MI
Practice Address - Zip Code:48173-1014
Practice Address - Country:US
Practice Address - Phone:313-723-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-01
Last Update Date:2025-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X, 156F00000X
MI7401001944103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No156F00000XEye and Vision Services ProvidersTechnician/Technologist