Provider Demographics
NPI:1033395678
Name:MINNICK, MEGAN MARIA (LPCC)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:MARIA
Last Name:MINNICK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 966
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92822-0966
Mailing Address - Country:US
Mailing Address - Phone:562-665-0226
Mailing Address - Fax:714-987-3061
Practice Address - Street 1:425 W BONITA AVE STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2543
Practice Address - Country:US
Practice Address - Phone:562-665-0226
Practice Address - Fax:714-987-3061
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA157101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124100383Medicaid