Provider Demographics
NPI:1205082815
Name:MIX, MARY E (LMHC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:MIX
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 S MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:IA
Mailing Address - Zip Code:50036-4899
Mailing Address - Country:US
Mailing Address - Phone:515-432-7983
Mailing Address - Fax:515-432-7657
Practice Address - Street 1:105 S MARSHALL ST
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:IA
Practice Address - Zip Code:50036-4899
Practice Address - Country:US
Practice Address - Phone:515-432-7983
Practice Address - Fax:515-432-7657
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00780101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0015180Medicaid