Provider Demographics
NPI:1992249742
Name:MINOR, AMY LYNN (MA, LCPC)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:MINOR
Suffix:
Gender:F
Credentials:MA, LCPC
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 786
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-0786
Mailing Address - Country:US
Mailing Address - Phone:618-567-8650
Mailing Address - Fax:618-551-2676
Practice Address - Street 1:5090 HUMBERT ROAD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035
Practice Address - Country:US
Practice Address - Phone:618-466-0295
Practice Address - Fax:618-551-2676
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
IL180010630101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180010630OtherSTATE LICENSE - LCPC