Provider Demographics
NPI:1760548366
Name:ANTONELLO, STEPHEN JOHN (PHD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:JOHN
Last Name:ANTONELLO
Suffix:
Gender:M
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 1:66 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1390103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103667OtherUCARE
MN148547400Medicaid
P00393789OtherRAILROAD MEDICARE INDIV#
6119337OtherMEDICA
MNOE222ANOtherBC BS INDIVIDUAL ID
MNHP40542OtherHEALTH PARTNERS INDIVIDUA
MN680002243Medicare PIN