Provider Demographics
NPI:1902456510
Name:MUTZ, AMY M (LSW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
Last Name:MUTZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 WASHINGTON AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47714-0900
Mailing Address - Country:US
Mailing Address - Phone:812-479-1916
Mailing Address - Fax:
Practice Address - Street 1:4411 WASHINGTON AVE STE 300
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47714-0900
Practice Address - Country:US
Practice Address - Phone:812-479-1916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99094502A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200238820Medicaid