Provider Demographics
NPI:1841644283
Name:MIXON, WILLIAM THOMAS (PT, DPT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:THOMAS
Last Name:MIXON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 OSIGIAN BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8968
Mailing Address - Country:US
Mailing Address - Phone:478-333-3075
Mailing Address - Fax:478-333-3484
Practice Address - Street 1:620 J L WHITE DR STE 110
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-4897
Practice Address - Country:US
Practice Address - Phone:706-692-9080
Practice Address - Fax:706-692-1199
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT012275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist