Provider Demographics
NPI:1669782322
Name:MINOR, DALE MICHAEL (PHD)
Entity type:Individual
Prefix:PROF
First Name:DALE
Middle Name:MICHAEL
Last Name:MINOR
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:DALE
Other - Middle Name:MICHAEL
Other - Last Name:MINOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, PCC, LICDC, CRC
Mailing Address - Street 1:94 COLUMBUS ROAD
Mailing Address - Street 2:SUITE A4
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1312
Mailing Address - Country:US
Mailing Address - Phone:740-592-4615
Mailing Address - Fax:740-592-4615
Practice Address - Street 1:8699 TERRELL ROAD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-9325
Practice Address - Country:US
Practice Address - Phone:740-592-5195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0008212101Y00000X
OH061009101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH12128803OtherCAQH