Healthcare Provider Details

I. General information

NPI: 1295211175
Provider Name (Legal Business Name): ANTONIA ROVER LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2018
Last Update Date: 07/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 WALLINGFORD DR APT B
RALEIGH NC
27616-5350
US

IV. Provider business mailing address

PO BOX 1964
WAKE FOREST NC
27588-1964
US

V. Phone/Fax

Practice location:
  • Phone: 336-327-0849
  • Fax:
Mailing address:
  • Phone: 336-327-0849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP012507
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: