Provider Demographics
NPI:1770701641
Name:MIXON, HOLLY ANN (MS CCC SLP)
Entity type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:ANN
Last Name:MIXON
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20250 WHITE RD
Mailing Address - Street 2:
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6430
Mailing Address - Country:US
Mailing Address - Phone:228-218-3362
Mailing Address - Fax:
Practice Address - Street 1:4214 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5975
Practice Address - Country:US
Practice Address - Phone:228-218-3362
Practice Address - Fax:228-872-9370
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS1189235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS200002991Medicaid