Provider Demographics
NPI:1750055117
Name:MIXON, MIRIAM A (LCSW)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:A
Last Name:MIXON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 PACIFIC COAST HWY APT 105
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-4859
Mailing Address - Country:US
Mailing Address - Phone:915-227-5636
Mailing Address - Fax:213-295-3714
Practice Address - Street 1:3543 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-3945
Practice Address - Country:US
Practice Address - Phone:915-227-5636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical