Basic Information
| Provider Information | |||||||||
| NPI: | 1013161090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONIA | ||||||||
| FirstName: | JONI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ANTONIA | ||||||||
| OtherFirstName: | JONI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652512388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085891829 | ||||||||
| FaxNumber: | 8085892610 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | FULTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652512388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085891829 | ||||||||
| FaxNumber: | 8085892610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2008 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 2017005884 | MO | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 09925760 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.