Provider Demographics
NPI:1891195111
Name:MINICK, ELISE (SCHOOL PSYCHOLOGIST)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:MINICK
Suffix:
Gender:F
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9769D NOBLE LN
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-9157
Mailing Address - Country:US
Mailing Address - Phone:419-605-8287
Mailing Address - Fax:
Practice Address - Street 1:9769D NOBLE LN
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-9157
Practice Address - Country:US
Practice Address - Phone:419-605-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20933633103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool