Provider Demographics
NPI:1710530175
Name:MINECK, BEN
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:
Last Name:MINECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 RANMAR CT
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:IA
Mailing Address - Zip Code:52227-9592
Mailing Address - Country:US
Mailing Address - Phone:319-423-2244
Mailing Address - Fax:
Practice Address - Street 1:204 GLENN ST SE STE 2
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1501
Practice Address - Country:US
Practice Address - Phone:319-423-2244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health