Healthcare Provider Details

I. General information

NPI: 1770346942
Provider Name (Legal Business Name): ANTOINE J WASHINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3442 177TH ST
LANSING IL
60438-2036
US

IV. Provider business mailing address

930 E 162ND ST
SOUTH HOLLAND IL
60473-2442
US

V. Phone/Fax

Practice location:
  • Phone: 708-527-6305
  • Fax:
Mailing address:
  • Phone: 708-677-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberW25201083167
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: