Provider Demographics
NPI:1215571906
Name:MIXON, BRANDON SHEA
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:SHEA
Last Name:MIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10730 CHURCH ST APT 266
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6652
Mailing Address - Country:US
Mailing Address - Phone:909-465-3151
Mailing Address - Fax:
Practice Address - Street 1:10730 CHURCH ST APT 266
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6652
Practice Address - Country:US
Practice Address - Phone:909-465-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty