Provider Demographics
NPI:1609422674
Name:MIXON, LEKISHA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LEKISHA
Middle Name:
Last Name:MIXON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1167 BUSH ST APT 607
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-5904
Mailing Address - Country:US
Mailing Address - Phone:305-205-0530
Mailing Address - Fax:
Practice Address - Street 1:400 29TH ST STE 405
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3549
Practice Address - Country:US
Practice Address - Phone:510-268-8544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY30979103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic