Provider Demographics
NPI:1407401771
Name:MIXON, AMBERLY JEAN (APSW)
Entity Type:Individual
Prefix:
First Name:AMBERLY
Middle Name:JEAN
Last Name:MIXON
Suffix:
Gender:F
Credentials:APSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3766 REDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-5839
Mailing Address - Country:US
Mailing Address - Phone:608-346-8843
Mailing Address - Fax:
Practice Address - Street 1:540 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-6314
Practice Address - Country:US
Practice Address - Phone:608-368-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI130393104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker