Provider Demographics
NPI:1629426770
Name:MITRANI, NICHOLAS (LPE-I)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MITRANI
Suffix:
Gender:M
Credentials:LPE-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 PRINCE STREET
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-9398
Mailing Address - Country:US
Mailing Address - Phone:501-932-0255
Mailing Address - Fax:
Practice Address - Street 1:4206 PRINCE STREET
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-9398
Practice Address - Country:US
Practice Address - Phone:501-932-0255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR18-22P103T00000X, 103TC1900X, 103TC2200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR232944719Medicaid