Healthcare Provider Details

I. General information

NPI: 1528402013
Provider Name (Legal Business Name): MRS. CANDICE MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 HENNESSY BLVD SUITE 101
BATON ROUGE LA
70808-4384
US

IV. Provider business mailing address

10030 RIVER RUN ESTATE DR
SAINT AMANT LA
70774-4701
US

V. Phone/Fax

Practice location:
  • Phone: 225-767-5004
  • Fax: 225-767-3117
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number06939
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: