Healthcare Provider Details

I. General information

NPI: 1578669198
Provider Name (Legal Business Name): MICHAEL THOMAS ANTON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W FOREST AVE STE 200
JACKSON TN
38301-3940
US

IV. Provider business mailing address

1804 HIGHWAY 45 BYP STE 604
JACKSON TN
38305-4403
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-9490
  • Fax: 731-541-9486
Mailing address:
  • Phone: 731-660-7971
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1273
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: