Healthcare Provider Details

I. General information

NPI: 1659512135
Provider Name (Legal Business Name): SHAN MIXON MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 N 12TH ST
GRAND JUNCTION CO
81501-2980
US

IV. Provider business mailing address

2021 N 12TH ST
GRAND JUNCTION CO
81501-2980
US

V. Phone/Fax

Practice location:
  • Phone: 970-257-6214
  • Fax:
Mailing address:
  • Phone: 970-257-6214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-3483
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: