Provider Demographics
NPI:1841335890
Name:WASHINGTON, ANTOINETTE MARIE
Entity type:Individual
Prefix:MS
First Name:ANTOINETTE
Middle Name:MARIE
Last Name:WASHINGTON
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 1:4513 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1438
Mailing Address - Country:US
Mailing Address - Phone:310-678-5561
Mailing Address - Fax:
Practice Address - Street 1:1045 W REDONDO BEACH BLVD STE 300
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4175
Practice Address - Country:US
Practice Address - Phone:323-241-6730
Practice Address - Fax:323-967-0614
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA657141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health