Provider Demographics
NPI:1912142571
Name:MINNICK, MELISSA ANN (LMFT)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:MINNICK
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0920
Mailing Address - Country:US
Mailing Address - Phone:909-387-8650
Mailing Address - Fax:
Practice Address - Street 1:900 E GILBERT ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0920
Practice Address - Country:US
Practice Address - Phone:909-387-8650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC51036106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist