=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891424487
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE MINTON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2022
-----------------------------------------------------
Last Update Date | 06/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 UNDERWOOD CT
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62526-1983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-233-6811
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1942 E CANTRELL ST
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-3214
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 178.013218
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------