Provider Demographics
NPI:1063625143
Name:KNOTTS, MIA G
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:G
Last Name:KNOTTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:NE
Mailing Address - Zip Code:69357-1438
Mailing Address - Country:US
Mailing Address - Phone:308-632-4412
Mailing Address - Fax:
Practice Address - Street 1:4110 AVENUE D
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4650
Practice Address - Country:US
Practice Address - Phone:308-632-4412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker