Provider Demographics
NPI:1154348027
Name:HINES, MIA D (LCSW)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:D
Last Name:HINES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MIA
Other - Middle Name:D
Other - Last Name:MUMFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3808 KISKADEE CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-1514
Mailing Address - Country:US
Mailing Address - Phone:317-402-5572
Mailing Address - Fax:
Practice Address - Street 1:2707 BROWNS LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7213
Practice Address - Country:US
Practice Address - Phone:890-972-4939
Practice Address - Fax:870-972-4911
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2028-C1041C0700X
IN34004822A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y907OtherBLUECROSS BLUESHIELD
AR5Y907Medicare ID - Type Unspecified