Healthcare Provider Details

I. General information

NPI: 1881162964
Provider Name (Legal Business Name): RYAN K MIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 WINCHESTER CV
CONVERSE TX
78109-0738
US

IV. Provider business mailing address

6800 PARK TEN BLVD STE 200S
SAN ANTONIO TX
78213-4293
US

V. Phone/Fax

Practice location:
  • Phone: 210-992-5646
  • Fax:
Mailing address:
  • Phone: 210-261-1000
  • Fax: 210-261-1821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number13626
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: