Provider Demographics
NPI:1063828176
Name:MINDEMAN, MIRIAM S (MA, LPC)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:S
Last Name:MINDEMAN
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 MARTIN AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520
Mailing Address - Country:US
Mailing Address - Phone:309-647-1881
Mailing Address - Fax:
Practice Address - Street 1:229 MARTIN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2520
Practice Address - Country:US
Practice Address - Phone:309-647-1881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008716101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor