Provider Demographics
NPI:1750892758
Name:MINNICK, REBECCA SUE
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:MINNICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 PALLISER ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-2965
Mailing Address - Country:US
Mailing Address - Phone:814-255-7495
Mailing Address - Fax:
Practice Address - Street 1:424 PALLISER ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-2965
Practice Address - Country:US
Practice Address - Phone:814-255-7495
Practice Address - Fax:814-255-7495
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL007140235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist