Healthcare Provider Details

I. General information

NPI: 1700363066
Provider Name (Legal Business Name): SUMMER A MIXON BS, CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 COLUMBIA ST
BOGALUSA LA
70427
US

IV. Provider business mailing address

542 COLUMBIA ST
BOGALUSA LA
70427-4720
US

V. Phone/Fax

Practice location:
  • Phone: 985-735-9448
  • Fax:
Mailing address:
  • Phone: 985-735-9448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: