Healthcare Provider Details

I. General information

NPI: 1295656361
Provider Name (Legal Business Name): KATHERINE ANTONUCCI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

578 WASHINGTON BLVD # 497
MARINA DEL REY CA
90292-5421
US

IV. Provider business mailing address

578 WASHINGTON BLVD # 497
MARINA DEL REY CA
90292-5421
US

V. Phone/Fax

Practice location:
  • Phone: 973-945-1185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMFT164624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: