MEDICARE: MISS MICHELE MARIE MIXON MSW, LCSW, BACS

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	104100000X	Social Worker	8769	LA

General Provider Information

NPI Number	:	1902915143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MICHELE MARIE MIXON MSW, LCSW, BACS

Provider Business Mailing Address
First Line	:	2244 11TH ST
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-1824
Country	:	US
Telephone Number	:	225-266-8122
Fax Number	:	504-617-7983

Provider Business Practice Location Address
First Line	:	2244 11TH ST
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-1824
Country	:	US
Telephone Number	:	225-266-8122
Fax Number	:	504-617-7983

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	11/21/2014

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