Provider Demographics
NPI:1720485584
Name:ANTONACCI, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:ANTONACCI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 E RAMON RD UNIT 47
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-7747
Mailing Address - Country:US
Mailing Address - Phone:818-850-1525
Mailing Address - Fax:
Practice Address - Street 1:1050 E RAMON RD UNIT 47
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-7747
Practice Address - Country:US
Practice Address - Phone:818-850-1525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-21
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32573103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01536011OtherMEDI-CAL