Provider Demographics
NPI:1568214955
Name:OLDMIXON, ELISABETH (LSW)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:
Last Name:OLDMIXON
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 1:3409 LASSITER FALLS CIR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6973
Mailing Address - Country:US
Mailing Address - Phone:201-725-0639
Mailing Address - Fax:
Practice Address - Street 1:171 MARKET SQ STE 206B
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2930
Practice Address - Country:US
Practice Address - Phone:617-816-9011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-01
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
NJ44SL05399600104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor