Provider Demographics
NPI:1093727687
Name:MINTON, MARLA D (MSSW LCSW)
Entity Type:Individual
Prefix:
First Name:MARLA
Middle Name:D
Last Name:MINTON
Suffix:
Gender:F
Credentials:MSSW LCSW
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 8082
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47716-8082
Mailing Address - Country:US
Mailing Address - Phone:812-420-0020
Mailing Address - Fax:812-789-2458
Practice Address - Street 1:1101 N ROYAL AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-7845
Practice Address - Country:US
Practice Address - Phone:812-420-0020
Practice Address - Fax:812-789-2458
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003950A1041C0700X
IN39001064A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000752449OtherANTHEM
IN11609129OtherCAQH
IN000000752449OtherANTHEM