Provider Demographics
NPI:1164474904
Name:MITCHELL, AMELIA JO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:JO
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 CLAYTONIA TER
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-2126
Mailing Address - Country:US
Mailing Address - Phone:805-674-2595
Mailing Address - Fax:
Practice Address - Street 1:1526 CLAYTONIA TER
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-2126
Practice Address - Country:US
Practice Address - Phone:805-674-2595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012001260103TC0700X
CAPSY17696103TH0100X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2012001260OtherLICENSE
OPL176960Medicare ID - Type Unspecified