Provider Demographics
NPI:1316139587
Name:ANTONSON, DESIREE MILNE (MS LPA)
Entity type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:MILNE
Last Name:ANTONSON
Suffix:
Gender:F
Credentials:MS LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 BATH AVE
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2696
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:
Practice Address - Street 1:300 FOXGLOVE DR
Practice Address - Street 2:
Practice Address - City:MOUNT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9769
Practice Address - Country:US
Practice Address - Phone:859-498-2135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0988103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical