Healthcare Provider Details

I. General information

NPI: 1487248597
Provider Name (Legal Business Name): MALORI BETH MIXON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 W RUTH AVE
ATOKA OK
74525-4002
US

IV. Provider business mailing address

948 W 13TH ST
ATOKA OK
74525-3425
US

V. Phone/Fax

Practice location:
  • Phone: 918-649-7989
  • Fax:
Mailing address:
  • Phone: 918-649-7989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: