Provider Demographics
NPI:1326328410
Name:MINNICK, KENNETH LEROY
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEROY
Last Name:MINNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:MR
Other - First Name:KENNY
Other - Middle Name:
Other - Last Name:MINNICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BA, CATC
Mailing Address - Street 1:7212 ORANGETHORPE AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-3341
Mailing Address - Country:US
Mailing Address - Phone:714-449-1125
Mailing Address - Fax:714-562-8729
Practice Address - Street 1:7212 ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-3341
Practice Address - Country:US
Practice Address - Phone:714-449-1125
Practice Address - Fax:714-562-8729
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health