Provider Demographics
NPI:1720366693
Name:MINOR, AMANDA JO (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:MINOR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4520
Mailing Address - Country:US
Mailing Address - Phone:208-234-2646
Mailing Address - Fax:208-232-0035
Practice Address - Street 1:409 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4520
Practice Address - Country:US
Practice Address - Phone:208-234-2646
Practice Address - Fax:208-232-0035
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4530101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional