MEDICARE: MR. MATT ELI MIXON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1336586288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATT ELI MIXON

Provider Business Mailing Address
First Line	:	16039 GREEN SPRINGS DR
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89511-8161
Country	:	US
Telephone Number	:	775-848-5614
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 W MOANA LN
Second Line	:	SUITE 2
City	:	RENO
State	:	NV
Zip	:	89509-4775
Country	:	US
Telephone Number	:	775-337-2394
Fax Number	:	775-337-9570

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2013
Last Update Date	:	08/22/2013

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