Provider Demographics
NPI:1295123693
Name:MINNER, PERRY JR (LCSW)
Entity type:Individual
Prefix:
First Name:PERRY
Middle Name:
Last Name:MINNER
Suffix:JR
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 1:430 E LASALLE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2724
Mailing Address - Country:US
Mailing Address - Phone:574-299-8595
Mailing Address - Fax:574-299-8598
Practice Address - Street 1:430 E LASALLE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-2724
Practice Address - Country:US
Practice Address - Phone:574-299-8595
Practice Address - Fax:574-299-8598
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005929A1041C0700X
IN87000014A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)