Provider Demographics
NPI:1720216864
Name:MINNELLA, MICHAEL EDWARD (LCPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:MINNELLA
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 1:8955 S KOMENSKY AVE
Mailing Address - Street 2:
Mailing Address - City:HOMETOWN
Mailing Address - State:IL
Mailing Address - Zip Code:60456-1221
Mailing Address - Country:US
Mailing Address - Phone:708-425-0661
Mailing Address - Fax:
Practice Address - Street 1:8955 S KOMENSKY AVE
Practice Address - Street 2:
Practice Address - City:HOMETOWN
Practice Address - State:IL
Practice Address - Zip Code:60456-1221
Practice Address - Country:US
Practice Address - Phone:708-425-0661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-28
Last Update Date:2009-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.005220101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health