Healthcare Provider Details

I. General information

NPI: 1720328446
Provider Name (Legal Business Name): STANLEY THOMAS ANTONELLI III L.C.S.W., L.C.A.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4004 PLEASANT DR
KOKOMO IN
46902-5858
US

IV. Provider business mailing address

4004 PLEASANT DR
KOKOMO IN
46902-5858
US

V. Phone/Fax

Practice location:
  • Phone: 574-727-1833
  • Fax:
Mailing address:
  • Phone: 574-727-1833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number87001442A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34005677A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1619240
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: