Provider Demographics
NPI:1922177591
Name:MINK, MICHAEL JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:MINK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 INGALSIDE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12083-2037
Mailing Address - Country:US
Mailing Address - Phone:518-965-1676
Mailing Address - Fax:
Practice Address - Street 1:77 ROUTE 26A
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12083
Practice Address - Country:US
Practice Address - Phone:518-965-1676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0399681041C0700X
TX066891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical