Provider Demographics
NPI:1073810370
Name:MIXON, CAROLYN LEE
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LEE
Last Name:MIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E HILLCREST BLVD
Mailing Address - Street 2:1
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-2418
Mailing Address - Country:US
Mailing Address - Phone:310-491-8765
Mailing Address - Fax:
Practice Address - Street 1:5201 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-3527
Practice Address - Country:US
Practice Address - Phone:323-781-3026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-22
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1006031525101YA0400X
106H00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist