Healthcare Provider Details

I. General information

NPI: 1912510512
Provider Name (Legal Business Name): CHRISTIAN JAMES MIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24100 CHAGRIN BLVD
BEACHWOOD OH
44122-5535
US

IV. Provider business mailing address

3791 COVINGTON RD
SOUTH EUCLID OH
44121-1901
US

V. Phone/Fax

Practice location:
  • Phone: 800-642-4560
  • Fax:
Mailing address:
  • Phone: 216-798-5340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.2207257
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: