Provider Demographics
NPI:1518051069
Name:MINSON, MARK IRA (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:IRA
Last Name:MINSON
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 1:4710 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4879
Mailing Address - Country:US
Mailing Address - Phone:561-999-9890
Mailing Address - Fax:561-999-9454
Practice Address - Street 1:4710 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-4879
Practice Address - Country:US
Practice Address - Phone:561-999-9890
Practice Address - Fax:561-999-9454
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3478103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75598Medicare ID - Type Unspecified