Provider Demographics
NPI:1215131420
Name:ANTILLON, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:ANTILLON
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 1:720 WIND RIVER DR
Mailing Address - Street 2:B
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-5725
Mailing Address - Country:US
Mailing Address - Phone:307-875-5781
Mailing Address - Fax:
Practice Address - Street 1:720 WIND RIVER DR
Practice Address - Street 2:B
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5725
Practice Address - Country:US
Practice Address - Phone:307-875-5781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services