Provider Demographics
NPI:1700868395
Name:MINER, ILENE D (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ILENE
Middle Name:D
Last Name:MINER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 VENICE BLVD
Mailing Address - Street 2:APT 210
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5924
Mailing Address - Country:US
Mailing Address - Phone:310-740-7304
Mailing Address - Fax:
Practice Address - Street 1:1891 EFFIE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-1711
Practice Address - Country:US
Practice Address - Phone:323-644-2000
Practice Address - Fax:323-666-1417
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN4C68Medicare ID - Type UnspecifiedMEDICARE