MEDICARE: MIRIAM A MIXON LCSW

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1750055117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM A MIXON LCSW

Provider Business Mailing Address
First Line	:	900 PACIFIC COAST HWY APT 105
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-4859
Country	:	US
Telephone Number	:	915-227-5636
Fax Number	:	213-295-3714

Provider Business Practice Location Address
First Line	:	3543 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-3945
Country	:	US
Telephone Number	:	915-227-5636
Fax Number	:

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

Provider Enumeration Date	:	08/08/2021
Last Update Date	:	08/08/2021

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