Healthcare Provider Details

I. General information

NPI: 1033916937
Provider Name (Legal Business Name): SUSAN LAMARR MIXAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5720 S 77TH ST
RALSTON NE
68127-4202
US

IV. Provider business mailing address

5720 S 77TH ST
RALSTON NE
68127-4202
US

V. Phone/Fax

Practice location:
  • Phone: 531-200-0563
  • Fax:
Mailing address:
  • Phone: 531-200-0563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: