Provider Demographics
NPI:1063094217
Name:MIX, CATHERINE HELENE (CCSS WORKER)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:HELENE
Last Name:MIX
Suffix:
Gender:F
Credentials:CCSS WORKER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1424 DEBORAH RD SE STE 205
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6619
Mailing Address - Country:US
Mailing Address - Phone:505-750-4855
Mailing Address - Fax:
Practice Address - Street 1:1424 DEBORAH RD SE STE 205
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6619
Practice Address - Country:US
Practice Address - Phone:505-636-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM502514253OtherDRIVERS LICENSE