Provider Demographics
NPI:1194875377
Name:MINARDI, NICHOLAS GEORGE (PHD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:GEORGE
Last Name:MINARDI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3409 WHITEHORSE AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1067
Mailing Address - Country:US
Mailing Address - Phone:209-577-5065
Mailing Address - Fax:
Practice Address - Street 1:3409 WHITEHORSE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1067
Practice Address - Country:US
Practice Address - Phone:209-577-5065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13926103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical