Healthcare Provider Details

I. General information

NPI: 1275061194
Provider Name (Legal Business Name): MIGUELINA MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9166 ANAHEIM PL STE 200
RANCHO CUCAMONGA CA
91730-8547
US

IV. Provider business mailing address

830 REGULO PL APT 2014
CHULA VISTA CA
91910-7722
US

V. Phone/Fax

Practice location:
  • Phone: 909-481-1547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: