Healthcare Provider Details

I. General information

NPI: 1326328410
Provider Name (Legal Business Name): MR. KENNETH LEROY MINNICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KENNY MINNICK BA, CATC

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 08/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 ORANGETHORPE AVE
BUENA PARK CA
90621-3341
US

IV. Provider business mailing address

7212 ORANGETHORPE AVE
BUENA PARK CA
90621-3341
US

V. Phone/Fax

Practice location:
  • Phone: 714-449-1125
  • Fax: 714-562-8729
Mailing address:
  • Phone: 714-449-1125
  • Fax: 714-562-8729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: