Basic Information
| Provider Information | |||||||||
| NPI: | 1730293457 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANTONUCCIO | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | PROF. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.H.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 W 2ND ST STE 235F | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895035353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757841223 | ||||||||
| FaxNumber: | 7753272006 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W 2ND ST STE 216 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895035353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757846388 | ||||||||
| FaxNumber: | 7757841428 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY104 | NV | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 002616051 | 05 | NV | MEDICAID |