Healthcare Provider Details

I. General information

NPI: 1407401771
Provider Name (Legal Business Name): AMBERLY JEAN MIXON APSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 E GRAND AVE
BELOIT WI
53511-6314
US

IV. Provider business mailing address

3766 REDSTONE DR
JANESVILLE WI
53548-5839
US

V. Phone/Fax

Practice location:
  • Phone: 608-368-8087
  • Fax:
Mailing address:
  • Phone: 608-346-8843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number130393
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: