Healthcare Provider Details

I. General information

NPI: 1275001620
Provider Name (Legal Business Name): MATTHEW MIXON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2018
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15318 14TH AVENUE CT E
TACOMA WA
98445-2496
US

IV. Provider business mailing address

15318 14TH AVENUE CT E
TACOMA WA
98445-2496
US

V. Phone/Fax

Practice location:
  • Phone: 253-324-3616
  • Fax:
Mailing address:
  • Phone: 253-324-3583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMG61438772
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: