Provider Demographics
NPI:1922312164
Name:MITZEL, AMANDA EMILY (LCSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:EMILY
Last Name:MITZEL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 E POPLAR ST STE C&D
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2532
Mailing Address - Country:US
Mailing Address - Phone:479-435-6047
Mailing Address - Fax:479-755-3595
Practice Address - Street 1:130 E POPLAR ST STE CANDD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2532
Practice Address - Country:US
Practice Address - Phone:479-435-6047
Practice Address - Fax:479-755-3595
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR101YM0800X
AR2506-M104100000X
AR3666-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR207147719Medicaid