Provider Demographics
NPI:1699113001
Name:MINICH, CORA RENEA (LMT, CMMP)
Entity type:Individual
Prefix:
First Name:CORA
Middle Name:RENEA
Last Name:MINICH
Suffix:
Gender:F
Credentials:LMT, CMMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 COURT ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-2408
Mailing Address - Country:US
Mailing Address - Phone:419-355-8440
Mailing Address - Fax:
Practice Address - Street 1:510 COURT STREET
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420
Practice Address - Country:US
Practice Address - Phone:419-355-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.021029172M00000X
021029225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No172M00000XOther Service ProvidersMechanotherapist