Provider Demographics
NPI:1487786935
Name:MINNIS, KERRY (LCSW, LMFT, LCAC)
Entity type:Individual
Prefix:MR
First Name:KERRY
Middle Name:
Last Name:MINNIS
Suffix:
Gender:M
Credentials:LCSW, LMFT, LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10155 E THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-9350
Mailing Address - Country:US
Mailing Address - Phone:317-862-1821
Mailing Address - Fax:
Practice Address - Street 1:610 E SOUTHPORT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-8581
Practice Address - Country:US
Practice Address - Phone:317-783-8477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34000534A1041C0700X
IN35000242A106H00000X
IN87000437A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)