Provider Demographics
NPI:1407653108
Name:MINEMYER, DEREK
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:MINEMYER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 7TH ST W APT A
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-5287
Mailing Address - Country:US
Mailing Address - Phone:406-471-2841
Mailing Address - Fax:
Practice Address - Street 1:644 4TH AVE W
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5206
Practice Address - Country:US
Practice Address - Phone:406-607-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT714961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty