Provider Demographics
NPI:1548600307
Name:MIXDORF, GEORGIA (LSW)
Entity Type:Individual
Prefix:
First Name:GEORGIA
Middle Name:
Last Name:MIXDORF
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-2331
Mailing Address - Country:US
Mailing Address - Phone:262-547-6557
Mailing Address - Fax:262-547-3644
Practice Address - Street 1:N14W23755 STONE RIDGE DR
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1147
Practice Address - Country:US
Practice Address - Phone:262-547-6557
Practice Address - Fax:262-547-3644
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1341-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical