Healthcare Provider Details

I. General information

NPI: 1750055117
Provider Name (Legal Business Name): MIRIAM A MIXON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2021
Last Update Date: 08/08/2021
Certification Date: 08/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3543 N PULASKI RD
CHICAGO IL
60641-3945
US

IV. Provider business mailing address

900 PACIFIC COAST HWY APT 105
HUNTINGTON BEACH CA
92648-4859
US

V. Phone/Fax

Practice location:
  • Phone: 915-227-5636
  • Fax:
Mailing address:
  • Phone: 915-227-5636
  • Fax: 213-295-3714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: