Provider Demographics
NPI:1740763531
Name:MIXON, BRIDGET LOUISE (MSW)
Entity Type:Individual
Prefix:
First Name:BRIDGET
Middle Name:LOUISE
Last Name:MIXON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11725 LONG SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-2421
Mailing Address - Country:US
Mailing Address - Phone:410-960-2781
Mailing Address - Fax:
Practice Address - Street 1:22776 THREE NOTCH RD STE 102
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-3369
Practice Address - Country:US
Practice Address - Phone:301-880-4833
Practice Address - Fax:301-760-3472
Is Sole Proprietor?:No
Enumeration Date:2018-09-08
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD180011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD18001OtherBOARD OF SOCIAL WORK EXAMINERS