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General NPI Number Information
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NPI Number | 1275642969
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Entity Type | Individual
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Provider Name | SUSAN ELAINE MINYARD PH D
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Gender | Female
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1701 SOUTH PROSPECT AVENUE SUITE 8
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City | CHAMPAIGN
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State | IL
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Zip | 61820-7050
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Country | US
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Telephone | 217-355-9030
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Fax | 217-355-9066
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Provider Business Mailing Address
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Address Line | 1701 SOUTH PROSPECT AVENUE SUITE 8
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City | CHAMPAIGN
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State | IL
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Zip | 61820-7050
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Country | US
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Telephone | 217-355-9030
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Fax | 217-355-9066
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 20040161
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State | IL
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