Provider Demographics
NPI:1730390139
Name:MINERO, MICHELLE ELENA (MFT)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELENA
Last Name:MINERO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-2919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:707-762-4101
Practice Address - Street 1:320 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2919
Practice Address - Country:US
Practice Address - Phone:707-762-4016
Practice Address - Fax:707-762-4101
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31804106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist