Provider Demographics
NPI:1275194227
Name:PEARCE, ANTONIO (MS)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:PEARCE
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12968 FREDERICK STREET
Mailing Address - Street 2:SUITE D
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553
Mailing Address - Country:US
Mailing Address - Phone:951-242-7738
Mailing Address - Fax:
Practice Address - Street 1:12968 FREDERICK STREET
Practice Address - Street 2:SUITE D
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553
Practice Address - Country:US
Practice Address - Phone:951-242-7738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94024757390200000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program