Healthcare Provider Details

I. General information

NPI: 1255436713
Provider Name (Legal Business Name): SUSAN ANTICO LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15283 SOUTHERN MARTIN ST
WINTER GARDEN FL
34787-4873
US

IV. Provider business mailing address

15283 SOUTHERN MARTIN ST
WINTER GARDEN FL
34787-4873
US

V. Phone/Fax

Practice location:
  • Phone: 561-866-6897
  • Fax:
Mailing address:
  • Phone: 561-866-6897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH5649
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: