Healthcare Provider Details

I. General information

NPI: 1346055845
Provider Name (Legal Business Name): DAMETREA MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N ILLINOIS ST FL 16
INDIANAPOLIS IN
46204-1904
US

IV. Provider business mailing address

PO BOX 6250
AKRON OH
44312-0250
US

V. Phone/Fax

Practice location:
  • Phone: 317-732-8380
  • Fax: 855-892-0299
Mailing address:
  • Phone: 888-238-1818
  • Fax: 855-915-1521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-354119
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: