Provider Demographics
NPI:1336298843
Name:MINTZES, BARRY (PHD)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:
Last Name:MINTZES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-4215
Mailing Address - Country:US
Mailing Address - Phone:517-337-6545
Mailing Address - Fax:517-337-3010
Practice Address - Street 1:234 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-4215
Practice Address - Country:US
Practice Address - Phone:517-337-6545
Practice Address - Fax:517-337-3010
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301000969103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR65811Medicare UPIN
MIC36456004Medicare ID - Type Unspecified