Provider Demographics
NPI:1164993804
Name:MIXON, WADE (LCAS-A)
Entity Type:Individual
Prefix:MR
First Name:WADE
Middle Name:
Last Name:MIXON
Suffix:
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3331 EASY ST
Mailing Address - Street 2:
Mailing Address - City:DUNN
Mailing Address - State:NC
Mailing Address - Zip Code:28334-7988
Mailing Address - Country:US
Mailing Address - Phone:910-567-7067
Mailing Address - Fax:910-567-5552
Practice Address - Street 1:1480 MAPLE GROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-7692
Practice Address - Country:US
Practice Address - Phone:910-567-7155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23170101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1427087709Medicaid
NC01OtherN/A