Provider Demographics
NPI:1508182304
Name:MIXON, KANIECIA LASHEA (MS)
Entity Type:Individual
Prefix:
First Name:KANIECIA
Middle Name:LASHEA
Last Name:MIXON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KANIECIA
Other - Middle Name:LASHEA
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, LMFT
Mailing Address - Street 1:5198 ARLINGTON AVE # 106
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-2603
Mailing Address - Country:US
Mailing Address - Phone:951-796-3621
Mailing Address - Fax:
Practice Address - Street 1:9500 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5871
Practice Address - Country:US
Practice Address - Phone:909-980-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 63143106H00000X, 101YM0800X
CA101YM0800X
CA94323106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health