MEDICARE: KELLY PAUL MINOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1487788402
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY PAUL MINOR

Provider Business Mailing Address
First Line	:	6244 EL CAJON BLVD STE 15
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-3918
Country	:	US
Telephone Number	:	619-287-8225
Fax Number	:	619-287-4146

Provider Business Practice Location Address
First Line	:	6244 EL CAJON BLVD STE 15
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92115-3918
Country	:	US
Telephone Number	:	619-287-8225
Fax Number	:	619-287-4146

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	08/29/2011

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Directions to “ KELLY PAUL MINOR ” Practice Location

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