Healthcare Provider Details

I. General information

NPI: 1336644533
Provider Name (Legal Business Name): DEMARCO MIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N AURORA ST STE 1
STOCKTON CA
95202-2276
US

IV. Provider business mailing address

14895 E 14TH ST STE 465
SAN LEANDRO CA
94578-2989
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-9370
  • Fax:
Mailing address:
  • Phone: 510-346-7100
  • Fax: 510-346-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: