Provider Demographics
NPI:1164943072
Name:ANTONACCI, KORY (MSED, MT-BC, LPC)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:
Last Name:ANTONACCI
Suffix:
Gender:F
Credentials:MSED, MT-BC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 OLD POND ROAD
Mailing Address - Street 2:SUITE 706 B
Mailing Address - City:BRIDGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15017
Mailing Address - Country:US
Mailing Address - Phone:412-206-5849
Mailing Address - Fax:
Practice Address - Street 1:800 OLD POND RD STE 706B
Practice Address - Street 2:
Practice Address - City:BRIDGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15017-3415
Practice Address - Country:US
Practice Address - Phone:412-695-3232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009707101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional