Provider Demographics
NPI:1154211431
Name:GOLSON, MIXON JERMAINE
Entity type:Individual
Prefix:
First Name:MIXON
Middle Name:JERMAINE
Last Name:GOLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20476 BEECH DALY RD
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48240-1037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20476 BEECH DALY RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-1037
Practice Address - Country:US
Practice Address - Phone:313-989-5253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician