Provider Demographics
NPI:1801027651
Name:ANTILLON, DESTINEE (PROGRAM ADMINISTRATO)
Entity Type:Individual
Prefix:
First Name:DESTINEE
Middle Name:
Last Name:ANTILLON
Suffix:
Gender:F
Credentials:PROGRAM ADMINISTRATO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3686 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-1948
Mailing Address - Country:US
Mailing Address - Phone:951-801-2914
Mailing Address - Fax:
Practice Address - Street 1:3686 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-1948
Practice Address - Country:US
Practice Address - Phone:951-801-2914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health