Provider Demographics
NPI:1558612689
Name:HIXON, ANANYA (MA, MFT INTERN)
Entity Type:Individual
Prefix:
First Name:ANANYA
Middle Name:
Last Name:HIXON
Suffix:
Gender:F
Credentials:MA, MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2749
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94979-2749
Mailing Address - Country:US
Mailing Address - Phone:415-342-4895
Mailing Address - Fax:
Practice Address - Street 1:1480 LINCOLN AVE
Practice Address - Street 2:#8
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2084
Practice Address - Country:US
Practice Address - Phone:415-456-7724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-28
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 66935106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist