Provider Demographics
NPI:1306485743
Name:D'ANTILIO, SUSAN (LMHC)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:D'ANTILIO
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BELLEVUE AVE
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1560
Mailing Address - Country:US
Mailing Address - Phone:617-212-0304
Mailing Address - Fax:781-939-9945
Practice Address - Street 1:100 CUMMINGS CTR STE 307E
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6107
Practice Address - Country:US
Practice Address - Phone:978-922-2280
Practice Address - Fax:978-927-1758
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MALMHC10000026101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program