Provider Demographics
NPI:1477530723
Name:MINNICK, TERRY L (LCPC)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:L
Last Name:MINNICK
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7604 BRIDLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:IL
Mailing Address - Zip Code:61011-9013
Mailing Address - Country:US
Mailing Address - Phone:815-885-1195
Mailing Address - Fax:
Practice Address - Street 1:5702 ELAINE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2458
Practice Address - Country:US
Practice Address - Phone:815-229-7102
Practice Address - Fax:815-229-7108
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional