Provider Demographics
NPI:1497486583
Name:MIXON, SAMANTHA ELIZABETH (SLP)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:MIXON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-923-3420
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:1805 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-1919
Practice Address - Country:US
Practice Address - Phone:225-923-3420
Practice Address - Fax:225-922-9316
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherN/A