Provider Demographics
NPI:1730293457
Name:ANTONUCCIO, DAVID (PHD)
Entity Type:Individual
Prefix:PROF
First Name:DAVID
Middle Name:
Last Name:ANTONUCCIO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 W 2ND ST STE 235F
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-5353
Mailing Address - Country:US
Mailing Address - Phone:775-784-1223
Mailing Address - Fax:775-327-2006
Practice Address - Street 1:401 W 2ND ST STE 216
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-5353
Practice Address - Country:US
Practice Address - Phone:775-784-6388
Practice Address - Fax:775-784-1428
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPY104103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002616051Medicaid
NVR77322Medicare UPIN
NV002616051Medicaid