Provider Demographics
NPI:1780835470
Name:ANTONELLI, CHRISTINE MARIE (DSW, LCSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:DSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MCCLELLAN AVE
Mailing Address - Street 2:SUITE 101 EAST
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-4609
Mailing Address - Country:US
Mailing Address - Phone:856-488-9595
Mailing Address - Fax:
Practice Address - Street 1:2400 MCCLELLAN AVE
Practice Address - Street 2:SUITE 101 EAST
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-4609
Practice Address - Country:US
Practice Address - Phone:856-488-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-01
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC010197001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0094676Medicaid