Healthcare Provider Details

I. General information

NPI: 1740763531
Provider Name (Legal Business Name): BRIDGET LOUISE MIXON MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2018
Last Update Date: 09/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22776 THREE NOTCH RD STE 102
LEXINGTON PARK MD
20653-3369
US

IV. Provider business mailing address

11725 LONG SHADOW LN
LUSBY MD
20657-2421
US

V. Phone/Fax

Practice location:
  • Phone: 301-880-4833
  • Fax: 301-760-3472
Mailing address:
  • Phone: 410-960-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number18001
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: