Provider Demographics
NPI:1912460536
Name:ANTONENKO, ANDREY (AMFT)
Entity Type:Individual
Prefix:
First Name:ANDREY
Middle Name:
Last Name:ANTONENKO
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 CALIFORNIA AVE APT 208
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-3051
Mailing Address - Country:US
Mailing Address - Phone:714-460-3770
Mailing Address - Fax:
Practice Address - Street 1:7281 GARDEN GROVE BLVD STE H
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4212
Practice Address - Country:US
Practice Address - Phone:714-460-3770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103610101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty