Healthcare Provider Details

I. General information

NPI: 1457692295
Provider Name (Legal Business Name): AMY LITTLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 03/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 E 100 N
KOKOMO IN
46901-3413
US

IV. Provider business mailing address

1539 E 100 N
KOKOMO IN
46901-3413
US

V. Phone/Fax

Practice location:
  • Phone: 765-450-5657
  • Fax:
Mailing address:
  • Phone: 765-450-5657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34005533A
License Number StateIN

VIII. Authorized Official

Name: AMY LITTLE
Title or Position: SOLE MEMBER/OWNER
Credential: LCSW
Phone: 765-860-7123