MEDICARE: MICHELE MARIE MIXON, LCSW

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	1041C0700X	Clinical Social Worker	8769	LA

General Provider Information

NPI Number	:	1144619842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHELE MARIE MIXON, LCSW

Provider Business Mailing Address
First Line	:	2244 11TH ST
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-1824
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2244 11TH ST
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-1824
Country	:	US
Telephone Number	:	225-266-8122
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MICHELE MIXON
Credential	:	LCSW
Telephone Number	:	225-266-8122

Provider Enumeration Date	:	01/18/2015
Last Update Date	:	01/09/2017

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