Healthcare Provider Details

I. General information

NPI: 1477530723
Provider Name (Legal Business Name): TERRY L MINNICK LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5702 ELAINE DR
ROCKFORD IL
61108-2458
US

IV. Provider business mailing address

7604 BRIDLEWOOD RD
CALEDONIA IL
61011-9013
US

V. Phone/Fax

Practice location:
  • Phone: 815-229-7102
  • Fax: 815-229-7108
Mailing address:
  • Phone: 815-885-1195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: