Provider Demographics
NPI:1386164572
Name:ANTICO, ELLIE ROSE (BA)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:ROSE
Last Name:ANTICO
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4840 SE NAEF RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-4037
Mailing Address - Country:US
Mailing Address - Phone:415-816-7165
Mailing Address - Fax:
Practice Address - Street 1:4950 NE BELKNAP CT STE 205
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5115
Practice Address - Country:US
Practice Address - Phone:503-560-5822
Practice Address - Fax:888-503-2864
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health