Provider Demographics
NPI:1134220312
Name:MINTON, RAVAE (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:RAVAE
Middle Name:
Last Name:MINTON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:RAVAE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LCSW
Mailing Address - Street 1:1373 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3392
Mailing Address - Country:US
Mailing Address - Phone:208-737-9999
Mailing Address - Fax:208-736-4400
Practice Address - Street 1:1373 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3392
Practice Address - Country:US
Practice Address - Phone:208-737-9999
Practice Address - Fax:208-736-4400
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-248891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDL4280OtherBLUE CROSS
ID000010148212OtherBLUE SHIELD