Healthcare Provider Details

I. General information

NPI: 1992249742
Provider Name (Legal Business Name): AMY LYNN MINOR MA, LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 NORTHPORT DR
ALTON IL
62002-5904
US

IV. Provider business mailing address

PO BOX 786
GODFREY IL
62035-0786
US

V. Phone/Fax

Practice location:
  • Phone: 618-466-0295
  • Fax: 618-551-2676
Mailing address:
  • Phone: 618-567-8650
  • Fax: 618-551-2676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180010630
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: