1740763531 NPI number — BRIDGET LOUISE MIXON MSW

Table of content: BRIDGET LOUISE MIXON MSW (NPI 1740763531)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740763531 NPI number — BRIDGET LOUISE MIXON MSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIXON
Provider First Name:
BRIDGET
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740763531
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11725 LONG SHADOW LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUSBY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20657-2421
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-960-2781
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22776 THREE NOTCH RD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON PARK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20653-3369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-880-4833
Provider Business Practice Location Address Fax Number:
301-760-3472
Provider Enumeration Date:
09/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  18001 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 18001 . This is a "BOARD OF SOCIAL WORK EXAMINERS" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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