Provider Demographics
NPI:1841817251
Name:ANTONICIC, MARISA R
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:R
Last Name:ANTONICIC
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 1:1237 CALIFORNIA ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0618
Mailing Address - Country:US
Mailing Address - Phone:530-244-7074
Mailing Address - Fax:530-244-7065
Practice Address - Street 1:1616 WEST ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1726
Practice Address - Country:US
Practice Address - Phone:530-244-7074
Practice Address - Fax:530-244-7065
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9530101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)