Provider Demographics
NPI:1700307139
Name:MIXON, GLORIA (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:MIXON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 TANGLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-4110
Mailing Address - Country:US
Mailing Address - Phone:404-207-6348
Mailing Address - Fax:
Practice Address - Street 1:777 CLEVELAND AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7129
Practice Address - Country:US
Practice Address - Phone:404-207-6348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-06
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1221225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist