Healthcare Provider Details

I. General information

NPI: 1629930839
Provider Name (Legal Business Name): CARRIE VIXEN
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9711 WASHINGTONIAN BLVD STE 550
GAITHERSBURG MD
20878-5789
US

IV. Provider business mailing address

3600 ROUTE 66 STE 150
NEPTUNE NJ
07753-2645
US

V. Phone/Fax

Practice location:
  • Phone: 410-609-6357
  • Fax:
Mailing address:
  • Phone: 410-609-6357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: