Provider Demographics
NPI:1740408251
Name:MINSKY, PAUL J (PHD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:MINSKY
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 1:1749 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-2139
Mailing Address - Country:US
Mailing Address - Phone:510-524-0700
Mailing Address - Fax:510-848-8778
Practice Address - Street 1:2006 DWIGHT WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2633
Practice Address - Country:US
Practice Address - Phone:510-524-0700
Practice Address - Fax:510-848-8778
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-22
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5981103TB0200X, 103TC0700X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00PL59810Medicare ID - Type Unspecified