Healthcare Provider Details

I. General information

NPI: 1598690398
Provider Name (Legal Business Name): AMANDA MITTLIEDER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2312 S DIXON RD STE 250
KOKOMO IN
46902-6426
US

IV. Provider business mailing address

2312 S DIXON RD STE 250
KOKOMO IN
46902-6426
US

V. Phone/Fax

Practice location:
  • Phone: 765-450-1028
  • Fax:
Mailing address:
  • Phone: 765-450-1082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34012421A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: