Provider Demographics
NPI:1376967919
Name:MINNICK, LAURA (MSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MINNICK
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:MCNALLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:255 W GENESSEE ST
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:IL
Mailing Address - Zip Code:60531-9786
Mailing Address - Country:US
Mailing Address - Phone:815-756-4875
Mailing Address - Fax:
Practice Address - Street 1:12 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-756-4875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor