Provider Demographics
NPI:1821675364
Name:MINNICK, CHARLES JACOB
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JACOB
Last Name:MINNICK
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 1:190 OVERLOOK BLVD
Mailing Address - Street 2:
Mailing Address - City:STRUTHERS
Mailing Address - State:OH
Mailing Address - Zip Code:44471-1615
Mailing Address - Country:US
Mailing Address - Phone:330-272-2759
Mailing Address - Fax:
Practice Address - Street 1:109 BLOSSOM LN
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-4284
Practice Address - Country:US
Practice Address - Phone:330-337-3033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA007496224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant