Provider Demographics
NPI:1417316001
Name:MUTALIPASSI, AMBER NICOLE (LCSW)
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:NICOLE
Last Name:MUTALIPASSI
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 1:624 MAIN AVE STE 3A
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1966
Mailing Address - Country:US
Mailing Address - Phone:701-373-1149
Mailing Address - Fax:
Practice Address - Street 1:624 MAIN AVE STE 3A
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1966
Practice Address - Country:US
Practice Address - Phone:701-373-1149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-11
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND5301104100000X, 1041C0700X
MN25046104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker