Healthcare Provider Details

I. General information

NPI: 1508182304
Provider Name (Legal Business Name): KANIECIA LASHEA MIXON M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KANIECIA LASHEA COOPER M.S., LMFT

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 HAVEN AVE STE 100
RANCHO CUCAMONGA CA
91730-5871
US

IV. Provider business mailing address

5198 ARLINGTON AVE # 106
RIVERSIDE CA
92504-2603
US

V. Phone/Fax

Practice location:
  • Phone: 909-980-6700
  • Fax:
Mailing address:
  • Phone: 951-796-3621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 63143
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMF 63143
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number94323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: