Healthcare Provider Details

I. General information

NPI: 1902915143
Provider Name (Legal Business Name): MICHELE MARIE MIXON MSW, LCSW, BACS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2244 11TH ST
MANDEVILLE LA
70471-1824
US

IV. Provider business mailing address

2244 11TH ST
MANDEVILLE LA
70471-1824
US

V. Phone/Fax

Practice location:
  • Phone: 225-266-8122
  • Fax: 504-617-7983
Mailing address:
  • Phone: 225-266-8122
  • Fax: 504-617-7983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8769
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: