Provider Demographics
NPI:1992916027
Name:D'ANTONIO, MICHAEL J (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:D'ANTONIO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 DARBY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-1718
Mailing Address - Country:US
Mailing Address - Phone:610-889-0419
Mailing Address - Fax:610-889-1537
Practice Address - Street 1:171 W LANCASTER AVE
Practice Address - Street 2:STE 3
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1775
Practice Address - Country:US
Practice Address - Phone:610-889-0419
Practice Address - Fax:610-889-1537
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS002142L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DA43152Medicare ID - Type Unspecified