Provider Demographics
NPI:1598842999
Name:ANTONETTI, ROBERTO CARLOS (PHD, LPC)
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:CARLOS
Last Name:ANTONETTI
Suffix:
Gender:M
Credentials:PHD, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 OAK GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2375
Mailing Address - Country:US
Mailing Address - Phone:214-720-1833
Mailing Address - Fax:214-979-0593
Practice Address - Street 1:3420 OAK GROVE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2375
Practice Address - Country:US
Practice Address - Phone:214-720-1833
Practice Address - Fax:214-979-0593
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX09645101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10011049OtherAMERIGROUP/CHIPS
TX129486OtherNORTH STAR/VALUE OPTIONS
TX1585LCOtherBLUE CROSS BLUE SHIELD