Provider Demographics
NPI:1235238049
Name:ANTONELLO, JUDY LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:LEE
Last Name:ANTONELLO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 DEER TRAIL PT
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55118-2750
Mailing Address - Country:US
Mailing Address - Phone:651-688-2335
Mailing Address - Fax:651-688-2669
Practice Address - Street 1:260 WENTWORTH AVE E # 124
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3525
Practice Address - Country:US
Practice Address - Phone:651-688-2335
Practice Address - Fax:651-688-2669
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0444103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP40905OtherHEALTH PARTNERS INDIVIDUA
MN31P64ANOtherBC BS GROUP ID
6146579OtherMEDICA
MN9233OtherHEALTH PARTNERS GROUP ID
MN104570OtherUCARE
MN100352600Medicaid
MN31P65ANOtherBC BS INDIVIDUAL ID
MN31P64ANOtherBC BS GROUP ID