Provider Demographics
NPI:1942718317
Name:PRIDEMORE, ANTONIA
Entity Type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:PRIDEMORE
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 1:12283 SUMAC DR
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-4013
Mailing Address - Country:US
Mailing Address - Phone:760-831-3084
Mailing Address - Fax:
Practice Address - Street 1:83912 AVENUE 45 STE 9
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3338
Practice Address - Country:US
Practice Address - Phone:760-347-0754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-18
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)