Provider Demographics
NPI:1720328446
Name:ANTONELLI, STANLEY THOMAS III (LCSW, LCAC)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:THOMAS
Last Name:ANTONELLI
Suffix:III
Gender:M
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 PLEASANT DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-5858
Mailing Address - Country:US
Mailing Address - Phone:574-727-1833
Mailing Address - Fax:
Practice Address - Street 1:4004 PLEASANT DR
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-5858
Practice Address - Country:US
Practice Address - Phone:574-727-1833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001442A101YA0400X
IN34005677A1041C0700X
IN16192401041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool