Provider Demographics
NPI:1558647008
Name:MIXON, SUSAN THOMAS (MS, JD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:THOMAS
Last Name:MIXON
Suffix:
Gender:F
Credentials:MS, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 ROSEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2232
Mailing Address - Country:US
Mailing Address - Phone:918-658-5438
Mailing Address - Fax:
Practice Address - Street 1:108 ROSEWOOD DR
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2232
Practice Address - Country:US
Practice Address - Phone:918-658-5438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YP2500X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200226970Medicaid