Provider Demographics
NPI:1225576689
Name:ANTONUCCI, JOHN (LAC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ANTONUCCI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2119 PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-5416
Mailing Address - Country:US
Mailing Address - Phone:504-810-9535
Mailing Address - Fax:
Practice Address - Street 1:2420 ATHANIA PKWY STE 102
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70001-1975
Practice Address - Country:US
Practice Address - Phone:504-810-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1435101YA0400X
LA6597101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)