Provider Demographics
NPI:1225368665
Name:AMORE-BROCCOLI, ANTONIA TERESA (MSW, LCSW)
Entity Type:Individual
Prefix:PROF
First Name:ANTONIA
Middle Name:TERESA
Last Name:AMORE-BROCCOLI
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:ANTONIA
Other - Last Name:BROCCOLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5905 SOQUEL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-2855
Mailing Address - Country:US
Mailing Address - Phone:831-566-4409
Mailing Address - Fax:831-462-2561
Practice Address - Street 1:4300 SOQUEL DR
Practice Address - Street 2:SPC 217
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-2105
Practice Address - Country:US
Practice Address - Phone:831-566-4409
Practice Address - Fax:831-462-2561
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW 239681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
12009903OtherCAQH
CA1225368665OtherNPI