Provider Demographics
NPI:1669268066
Name:ANTONIO, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:ANTONIO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25273 LAS PALOMAS DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-7508
Mailing Address - Country:US
Mailing Address - Phone:951-988-4067
Mailing Address - Fax:
Practice Address - Street 1:495 E RINCON ST STE 209
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-1379
Practice Address - Country:US
Practice Address - Phone:562-821-1291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician