Healthcare Provider Details

I. General information

NPI: 1770701641
Provider Name (Legal Business Name): HOLLY ANN MIXON MS CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4214 BIENVILLE BLVD
OCEAN SPRINGS MS
39564-5975
US

IV. Provider business mailing address

20250 WHITE RD
VANCLEAVE MS
39565-6430
US

V. Phone/Fax

Practice location:
  • Phone: 228-218-3362
  • Fax: 228-872-9370
Mailing address:
  • Phone: 228-218-3362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberS1189
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: