Healthcare Provider Details

I. General information

NPI: 1720860067
Provider Name (Legal Business Name): ANGEL M MINOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DAYTON ST
HAMILTON OH
45011-3455
US

IV. Provider business mailing address

1020 SYMMES RD
FAIRFIELD OH
45014-1844
US

V. Phone/Fax

Practice location:
  • Phone: 513-868-7654
  • Fax: 513-737-0026
Mailing address:
  • Phone: 513-645-4578
  • Fax: 513-883-1546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.171958
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: