Provider Demographics
NPI:1194415943
Name:ANTONIUS, TERENCE (SLP-CCC)
Entity type:Individual
Prefix:
First Name:TERENCE
Middle Name:
Last Name:ANTONIUS
Suffix:
Gender:M
Credentials:SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2907 SHELTER ISLAND DR # 105-534
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2743
Mailing Address - Country:US
Mailing Address - Phone:949-280-7707
Mailing Address - Fax:
Practice Address - Street 1:2131 SHELTER ISLAND DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-3106
Practice Address - Country:US
Practice Address - Phone:949-280-7707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP8999235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist