Healthcare Provider Details

I. General information

NPI: 1750722286
Provider Name (Legal Business Name): ANTOINETTE M THACKER LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 FAIRGROVE AVE STE E
HAMILTON OH
45011-1930
US

IV. Provider business mailing address

8778 COTTONWOOD DR
CINCINNATI OH
45231-4706
US

V. Phone/Fax

Practice location:
  • Phone: 513-795-7557
  • Fax: 513-737-4603
Mailing address:
  • Phone: 513-305-2218
  • Fax: 513-737-4603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1000009-SUPV
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.1000009-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: