Provider Demographics
NPI:1629545744
Name:USTIMOV, ANTONINA JULIA
Entity Type:Individual
Prefix:
First Name:ANTONINA
Middle Name:JULIA
Last Name:USTIMOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1358 BLUE OAKS BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-7040
Mailing Address - Country:US
Mailing Address - Phone:916-676-0488
Mailing Address - Fax:
Practice Address - Street 1:1358 BLUE OAKS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-7040
Practice Address - Country:US
Practice Address - Phone:916-676-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-26
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician