Healthcare Provider Details

I. General information

NPI: 1447868906
Provider Name (Legal Business Name): PSYCHOTHERAPY ASSOCIATES OF KOKOMO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2020
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 E SOUTHWAY BLVD STE 101
KOKOMO IN
46902-3577
US

IV. Provider business mailing address

217 E SOUTHWAY BLVD STE 101
KOKOMO IN
46902-3577
US

V. Phone/Fax

Practice location:
  • Phone: 765-480-0594
  • Fax:
Mailing address:
  • Phone: 765-480-0594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STANLEY THOMAS ANTONELLI III
Title or Position: CEO/PSYCHOTHERAPIST
Credential: LCSW, LCAC
Phone: 765-480-0594