Provider Demographics
NPI:1275642969
Name:MINYARD, SUSAN ELAINE (PH D)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:ELAINE
Last Name:MINYARD
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SOUTH PROSPECT AVENUE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7050
Mailing Address - Country:US
Mailing Address - Phone:217-355-9030
Mailing Address - Fax:217-355-9066
Practice Address - Street 1:1701 SOUTH PROSPECT AVENUE
Practice Address - Street 2:SUITE 8
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7050
Practice Address - Country:US
Practice Address - Phone:217-355-9030
Practice Address - Fax:217-355-9066
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040161103T00000X
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
K23294Medicare UPIN
212708Medicare ID - Type Unspecified