Healthcare Provider Details

I. General information

NPI: 1750725156
Provider Name (Legal Business Name): SUSAN ANTICO,MS,LMHC,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2013
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
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: SUSAN ANTICO
Title or Position: OWNER
Credential:
Phone: 561-866-6897