MEDICARE: NICHOLAS MITRANI LPE-I

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	103T00000X	Psychologist	18-22P	AR
2	103TC1900X	Counseling Psychologist	18-22P	AR
3	103TC2200X	Clinical Child & Adolescent Psychologist	18-22P	AR
4	103TC0700X	Clinical Psychologist	18-22P	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629426770
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS MITRANI LPE-I

Provider Business Mailing Address
First Line	:	4206 PRINCE STREET
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-9398
Country	:	US
Telephone Number	:	501-932-0255
Fax Number	:

Provider Business Practice Location Address
First Line	:	4206 PRINCE STREET
Second Line	:
City	:	CONWAY
State	:	AR
Zip	:	72034-9398
Country	:	US
Telephone Number	:	501-932-0255
Fax Number	:

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

Provider Enumeration Date	:	05/31/2016
Last Update Date	:	07/24/2019

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