Provider Demographics
NPI:1104679802
Name:MINOR, MICAH (LMSW)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:MINOR
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 1:213 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANAMOSA
Mailing Address - State:IA
Mailing Address - Zip Code:52205-5701
Mailing Address - Country:US
Mailing Address - Phone:319-224-0722
Mailing Address - Fax:877-728-2951
Practice Address - Street 1:105 JOHNSON ST NE
Practice Address - Street 2:SUITE 201
Practice Address - City:ELKADER
Practice Address - State:IA
Practice Address - Zip Code:52043
Practice Address - Country:US
Practice Address - Phone:563-929-3595
Practice Address - Fax:877-728-2951
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107581104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty