Provider Demographics
NPI:1104122951
Name:MINNICH, TAMELA ANN (LMSW)
Entity type:Individual
Prefix:MS
First Name:TAMELA
Middle Name:ANN
Last Name:MINNICH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX A
Mailing Address - Street 2:
Mailing Address - City:ZUNI
Mailing Address - State:NM
Mailing Address - Zip Code:87327-0166
Mailing Address - Country:US
Mailing Address - Phone:505-782-5821
Mailing Address - Fax:505-782-5505
Practice Address - Street 1:PO BOX A
Practice Address - Street 2:
Practice Address - City:ZUNI
Practice Address - State:NM
Practice Address - Zip Code:87327-0166
Practice Address - Country:US
Practice Address - Phone:505-782-5821
Practice Address - Fax:505-782-5505
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-067601041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool