Healthcare Provider Details

I. General information

NPI: 1558647008
Provider Name (Legal Business Name): SUSAN THOMAS MIXON M.S., J.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2011
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ROSEWOOD DR
POTEAU OK
74953-2232
US

IV. Provider business mailing address

108 ROSEWOOD DR
POTEAU OK
74953-2232
US

V. Phone/Fax

Practice location:
  • Phone: 918-658-5438
  • Fax:
Mailing address:
  • Phone: 918-658-5438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: