=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518218346
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY ABIGAIL MINNICK LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/19/2012
-----------------------------------------------------
Last Update Date | 01/20/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 719 N CENTER DR NW
-----------------------------------------------------
City | WALKER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49544-8215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-647-2595
-----------------------------------------------------
Fax | 616-785-5180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 719 N CENTER DR NW
-----------------------------------------------------
City | WALKER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49544-8215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-647-2595
-----------------------------------------------------
Fax | 616-785-5180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801095339
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------