Provider Demographics
NPI:1932542768
Name:MIXON, KATHRYN GRACE (MS, RN, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:GRACE
Last Name:MIXON
Suffix:
Gender:F
Credentials:MS, RN, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2612
Mailing Address - Country:US
Mailing Address - Phone:706-774-2166
Mailing Address - Fax:706-774-7542
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-2166
Practice Address - Fax:706-774-7542
Is Sole Proprietor?:No
Enumeration Date:2013-04-11
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6665235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist