Provider Demographics
NPI:1265897086
Name:ANTONELLI, LAURA ELLEN (MA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELLEN
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELLEN
Other - Last Name:GROGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:998 CROOKED HILL RD
Mailing Address - Street 2:BLDG 56
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1019
Mailing Address - Country:US
Mailing Address - Phone:631-761-3394
Mailing Address - Fax:
Practice Address - Street 1:998 CROOKED HILL RD
Practice Address - Street 2:BLDG 56
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1019
Practice Address - Country:US
Practice Address - Phone:631-761-3394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic