Provider Demographics
NPI:1477002582
Name:WIXON, EVA (BA)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:WIXON
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6370 24TH ST S
Mailing Address - Street 2:385
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-5380
Mailing Address - Country:US
Mailing Address - Phone:518-944-9745
Mailing Address - Fax:
Practice Address - Street 1:6370 24TH ST S
Practice Address - Street 2:385
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33712-5380
Practice Address - Country:US
Practice Address - Phone:518-944-9745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-30
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker