Provider Demographics
NPI:1275001620
Name:MIXON, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:15318 14TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98445-2496
Mailing Address - Country:US
Mailing Address - Phone:253-324-3583
Mailing Address - Fax:
Practice Address - Street 1:15318 14TH AVENUE CT E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98445-2496
Practice Address - Country:US
Practice Address - Phone:253-324-3616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-04
Last Update Date:2018-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)