Provider Demographics
NPI:1760695837
Name:NIXON, MICHELLE (EDD, LCMHC)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:NIXON
Suffix:
Gender:F
Credentials:EDD, LCMHC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:BENWARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EDD, LCMHC
Mailing Address - Street 1:PO BOX 735
Mailing Address - Street 2:
Mailing Address - City:ESCALANTE
Mailing Address - State:UT
Mailing Address - Zip Code:84726-0140
Mailing Address - Country:US
Mailing Address - Phone:435-669-5399
Mailing Address - Fax:
Practice Address - Street 1:32 W WINCHESTER ST STE 101
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-5609
Practice Address - Country:US
Practice Address - Phone:801-263-6367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
UT7569606-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1760695837Medicaid