Healthcare Provider Details

I. General information

NPI: 1073810370
Provider Name (Legal Business Name): CAROLYN LEE MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2011
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 S VERMONT AVE
LOS ANGELES CA
90037-3527
US

IV. Provider business mailing address

114 E HILLCREST BLVD 1
INGLEWOOD CA
90301-2418
US

V. Phone/Fax

Practice location:
  • Phone: 323-781-3026
  • Fax:
Mailing address:
  • Phone: 310-491-8765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1006031525
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: