Healthcare Provider Details

I. General information

NPI: 1861977134
Provider Name (Legal Business Name): JOHN DAVONE MIXON SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2018
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7240 E SOUTHGATE DR STE G
SACRAMENTO CA
95823-2627
US

IV. Provider business mailing address

7441 POWER INN RD APT B
SACRAMENTO CA
95828-4478
US

V. Phone/Fax

Practice location:
  • Phone: 916-391-4293
  • Fax: 916-391-4247
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: