Healthcare Provider Details

I. General information

NPI: 1588870349
Provider Name (Legal Business Name): SANDRA JEAN WIXSON PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 06/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROTUNDA 8, CASA # 163 ULLOA
ULLOA HEREDIA
NA
CR

IV. Provider business mailing address

P.O. BOX 025331 SJO 14229
MIAMI FL
33102
US

V. Phone/Fax

Practice location:
  • Phone: 1150625890526
  • Fax:
Mailing address:
  • Phone: 512-757-1178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number23293
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: