Provider Demographics
NPI:1124587696
Name:ANTONIO, ELISA
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 W 18TH ST APT C
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-4200
Mailing Address - Country:US
Mailing Address - Phone:949-278-6762
Mailing Address - Fax:
Practice Address - Street 1:1503 S COAST DR STE 212
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-1534
Practice Address - Country:US
Practice Address - Phone:949-278-6762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician