Provider Demographics
NPI:1619483153
Name:ANTONACCI, CAMILLE (OT)
Entity type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:
Last Name:ANTONACCI
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-286-1669
Mailing Address - Fax:314-627-7219
Practice Address - Street 1:4444 FOREST PARK AVE
Practice Address - Street 2:DEPT OCCUPATIONAL THERAPY, STE 2210
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-2212
Practice Address - Country:US
Practice Address - Phone:314-286-1669
Practice Address - Fax:314-627-7219
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022020088225X00000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO470138978Medicaid