Provider Demographics
NPI:1992168363
Name:MORRIS, MITZI (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:MITZI
Middle Name:
Last Name:MORRIS
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 HARRISON ST
Mailing Address - Street 2:PO BOX 13
Mailing Address - City:HICKMAN
Mailing Address - State:KY
Mailing Address - Zip Code:42050
Mailing Address - Country:US
Mailing Address - Phone:270-627-1247
Mailing Address - Fax:
Practice Address - Street 1:509 ELM ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3407
Practice Address - Country:US
Practice Address - Phone:270-627-1247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1050061744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management