MEDICARE: DR. AMELIA JO MITCHELL PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	2012001260	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2012001260	OTHER	MO	LICENSE

General Provider Information

NPI Number	:	1164474904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMELIA JO MITCHELL PSYD

Provider Business Mailing Address
First Line	:	1526 CLAYTONIA TER
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2126
Country	:	US
Telephone Number	:	805-674-2595
Fax Number	:

Provider Business Practice Location Address
First Line	:	1526 CLAYTONIA TER
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63117-2126
Country	:	US
Telephone Number	:	805-674-2595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	09/24/2015

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