=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285239087
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARRIE L MINIARD LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2020
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 250 CUSHMAN ST STE 4F
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-4665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-978-1943
-----------------------------------------------------
Fax | 360-838-4806
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 SLEATER KINNEY RD SE STE B189
-----------------------------------------------------
City | LACEY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98503-1150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-978-1943
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LW61509337
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | TPSW4575
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 209409
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------