Provider Demographics
NPI:1093935694
Name:MINIKEN, JUDITH LIANE (MS,MDH)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:LIANE
Last Name:MINIKEN
Suffix:
Gender:F
Credentials:MS,MDH
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:LIANE
Other - Last Name:MINIKEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMHC, CMHS
Mailing Address - Street 1:403 W STATE ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-6139
Mailing Address - Country:US
Mailing Address - Phone:360-637-9369
Mailing Address - Fax:360-637-9369
Practice Address - Street 1:403 W STATE ST
Practice Address - Street 2:SUITE 206
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-6139
Practice Address - Country:US
Practice Address - Phone:360-637-9369
Practice Address - Fax:360-637-9369
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00010642101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH00010642OtherSTATE OF WA LICENSE