Basic Information
| Provider Information | |||||||||
| NPI: | 1063805414 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MINNICH | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LPCA, LCASA, NCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 CRUTCHFIELD ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042771 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 309 CRUTCHFIELD ST | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277042754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195607305 | ||||||||
| FaxNumber: | 9197971962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2015 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | A11356 | NC | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YA0400X | 21213 | NC | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.