Provider Demographics
NPI:1619953692
Name:NITZA, AMY (PHD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:NITZA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:723 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46802-1403
Mailing Address - Country:US
Mailing Address - Phone:260-969-0915
Mailing Address - Fax:260-969-0917
Practice Address - Street 1:723 FULTON ST
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-1403
Practice Address - Country:US
Practice Address - Phone:260-969-0915
Practice Address - Fax:260-969-0917
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001630A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health