=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164943072
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KORY ANTONACCI M.S.ED., MT-BC, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2017
-----------------------------------------------------
Last Update Date | 09/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 OLD POND RD STE 706B
-----------------------------------------------------
City | BRIDGEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15017-3415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-695-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 800 OLD POND ROAD SUITE 706 B
-----------------------------------------------------
City | BRIDGEVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-206-5849
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | PC009707
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------