MEDICARE: ANTOINE J WASHINGTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TH0100X	Health Service Psychologist	W25201083167	IL

General Provider Information

NPI Number	:	1770346942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTOINE J WASHINGTON

Provider Business Mailing Address
First Line	:	930 E 162ND ST
Second Line	:
City	:	SOUTH HOLLAND
State	:	IL
Zip	:	60473-2442
Country	:	US
Telephone Number	:	708-677-6715
Fax Number	:

Provider Business Practice Location Address
First Line	:	3442 177TH ST
Second Line	:
City	:	LANSING
State	:	IL
Zip	:	60438-2036
Country	:	US
Telephone Number	:	708-527-6305
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2024
Last Update Date	:	01/31/2024

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