Provider Demographics
NPI:1861956419
Name:MIXON, MIRANDA (LCPC)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MIXON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9015 WOODYARD RD STE 206
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-4209
Mailing Address - Country:US
Mailing Address - Phone:240-580-9956
Mailing Address - Fax:
Practice Address - Street 1:9015 WOODYARD RD STE 206
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-4209
Practice Address - Country:US
Practice Address - Phone:240-580-9956
Practice Address - Fax:301-877-7110
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC9075101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health