Provider Demographics
NPI:1760031355
Name:PADUA, ANTONETTE SANTOS
Entity Type:Individual
Prefix:MRS
First Name:ANTONETTE
Middle Name:SANTOS
Last Name:PADUA
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 1:125 DARWIN LN
Mailing Address - Street 2:
Mailing Address - City:TALOFOFO
Mailing Address - State:GU
Mailing Address - Zip Code:96915-3723
Mailing Address - Country:US
Mailing Address - Phone:671-777-3202
Mailing Address - Fax:
Practice Address - Street 1:125 DARWIN LN
Practice Address - Street 2:
Practice Address - City:TALOFOFO
Practice Address - State:GU
Practice Address - Zip Code:96915-3723
Practice Address - Country:US
Practice Address - Phone:671-777-3202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GU135101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty