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General NPI Number Information
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NPI Number | 1760548366
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Entity Type | Individual
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Provider Name | STEPHEN JOHN ANTONELLO PH.D.
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Gender | Male
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 01/30/2017
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Provider Practice Location Address
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Address Line | 66 THOMPSON AVE E SUITE 102
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City | WEST ST PAUL
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State | MN
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Zip | 55118-3184
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Country | US
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Telephone | 651-688-2335
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Fax | 651-688-2669
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Provider Business Mailing Address
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Address Line | 825 DEER TRAIL PT
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City | MENDOTA HEIGHTS
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State | MN
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Zip | 55118-2750
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Country | US
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Telephone | 651-688-2335
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Fax | 651-688-2669
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP1390
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License Number State | MN
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