Provider Demographics
NPI:1740532050
Name:FITZWATER, AMY MARIE (PLPC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:FITZWATER
Suffix:
Gender:F
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 PINNACLE POINT DR
Mailing Address - Street 2:
Mailing Address - City:HOLTS SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:65043-2065
Mailing Address - Country:US
Mailing Address - Phone:573-424-2654
Mailing Address - Fax:
Practice Address - Street 1:601 W NIFONG BLVD
Practice Address - Street 2:SUITE 1B, BUILDING 1
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-6804
Practice Address - Country:US
Practice Address - Phone:573-442-9669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011033841101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program