Provider Demographics
NPI:1972371060
Name:ANTIUK, ALICIA MARIE (LADC, MHRT/C)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:ANTIUK
Suffix:
Gender:F
Credentials:LADC, MHRT/C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST MILLINOCKET
Mailing Address - State:ME
Mailing Address - Zip Code:04430-1220
Mailing Address - Country:US
Mailing Address - Phone:207-249-0840
Mailing Address - Fax:
Practice Address - Street 1:2323 MEDWAY RD
Practice Address - Street 2:
Practice Address - City:MEDWAY
Practice Address - State:ME
Practice Address - Zip Code:04460-3106
Practice Address - Country:US
Practice Address - Phone:207-249-0840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME35230171M00000X
MELC8637101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator