Individual
DR. JUDY LEE ANTONELLO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PH.D.
Contact information
Practice address
260 WENTWORTH AVE E # 124, WEST ST PAUL, MN 55118-3525
(651) 688-2335
(651) 688-2669
Mailing address
825 DEER TRAIL PT, MENDOTA HEIGHTS, MN 55118-2750
(651) 688-2335
(651) 688-2669
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
LP0444
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100352600
—
MN
01
—
104570
UCARE
MN
01
—
31P64AN
BC BS GROUP ID
MN
01
—
31P65AN
BC BS INDIVIDUAL ID
MN
01
—
6146579
MEDICA
—
01
—
9233
HEALTH PARTNERS GROUP ID
MN
01
—
HP40905
HEALTH PARTNERS INDIVIDUA
MN
Enumeration date
09/21/2006
Last updated
02/28/2021
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