Provider Demographics
NPI:1194159871
Name:ANTONIO, TIAGO BARCELOS (LCSW)
Entity type:Individual
Prefix:
First Name:TIAGO
Middle Name:BARCELOS
Last Name:ANTONIO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:
Practice Address - Street 1:8851 CENTER DR STE 312
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3050
Practice Address - Country:US
Practice Address - Phone:619-515-2383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA905291041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health