Provider Demographics
NPI:1447868906
Name:PSYCHOTHERAPY ASSOCIATES OF KOKOMO, LLC
Entity type:Organization
Organization Name:PSYCHOTHERAPY ASSOCIATES OF KOKOMO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ANTONELLI
Authorized Official - Suffix:III
Authorized Official - Credentials:LCSW, LCAC
Authorized Official - Phone:765-480-0594
Mailing Address - Street 1:217 E SOUTHWAY BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3577
Mailing Address - Country:US
Mailing Address - Phone:765-480-0594
Mailing Address - Fax:
Practice Address - Street 1:217 E SOUTHWAY BLVD STE 101
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3577
Practice Address - Country:US
Practice Address - Phone:765-480-0594
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty