Provider Demographics
NPI:1326147133
Name:STEPHEN J. ANTONELLO, INCORPORATED
Entity Type:Organization
Organization Name:STEPHEN J. ANTONELLO, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ANTONELLO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:651-688-2335
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 1:66 THOMPSON AVE E
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-3184
Practice Address - Country:US
Practice Address - Phone:651-688-2335
Practice Address - Fax:651-688-2669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1390103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF8617OtherRAILROAD MEDICARE GRP ID
MN103667OtherUCARE
MN59778ANOtherBC BS GROUP ID
MN760249900Medicaid
6119337OtherMEDICA
MN73464OtherHEALTH PARTNERS GROUP
MNC04462Medicare PIN