Healthcare Provider Details

I. General information

NPI: 1326861055
Provider Name (Legal Business Name): ALEX FELIX MINICK ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 S BASCOM AVE STE 1014
SAN JOSE CA
95128-3537
US

IV. Provider business mailing address

565 N 10TH ST # NA
SAN JOSE CA
95112-3216
US

V. Phone/Fax

Practice location:
  • Phone: 408-290-4790
  • Fax:
Mailing address:
  • Phone: 510-909-6947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: