Basic Information
| Provider Information | |||||||||
| NPI: | 1396871349 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONUCCI | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 E PIONEER AVE | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536978400 | ||||||||
| FaxNumber: | 2536978590 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 E PIONEER AVE | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98372 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536978400 | ||||||||
| FaxNumber: | 2536978590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | RC00005451 | WA | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.