Provider Demographics
NPI:1578156022
Name:ANTOINE, JOAQUIN
Entity Type:Individual
Prefix:MR
First Name:JOAQUIN
Middle Name:
Last Name:ANTOINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17219 132ND ST NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98329-5600
Mailing Address - Country:US
Mailing Address - Phone:253-858-1600
Mailing Address - Fax:
Practice Address - Street 1:2475 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2490
Practice Address - Country:US
Practice Address - Phone:360-876-9430
Practice Address - Fax:360-876-0713
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61036507101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61036507Medicaid