=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740763531
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIDGET LOUISE MIXON MSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/08/2018
-----------------------------------------------------
Last Update Date | 09/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22776 THREE NOTCH RD STE 102
-----------------------------------------------------
City | LEXINGTON PARK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20653-3369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-880-4833
-----------------------------------------------------
Fax | 301-760-3472
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11725 LONG SHADOW LN
-----------------------------------------------------
City | LUSBY
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20657-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-960-2781
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 18001
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------