Provider Demographics
NPI:1255681888
Name:MIX, JOANN DAWN (PT)
Entity Type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:DAWN
Last Name:MIX
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 HARTMAN LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62221-8402
Mailing Address - Country:US
Mailing Address - Phone:618-207-1610
Mailing Address - Fax:
Practice Address - Street 1:1201 HARTMAN LN
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-8402
Practice Address - Country:US
Practice Address - Phone:618-207-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018003225100000X
NJ40QA00986500225100000X
MO2010006857225100000X
HIPT-3992225100000X
ALPTH7173225100000X
GAPT011528225100000X
CA40574225100000X
KS11-05712225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist