Provider Demographics
NPI:1104110360
Name:MIXER, ALICE (LMSW)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:MIXER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 MINER ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103
Mailing Address - Country:US
Mailing Address - Phone:734-769-3134
Mailing Address - Fax:
Practice Address - Street 1:618 MINER ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-3116
Practice Address - Country:US
Practice Address - Phone:734-769-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801088031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$OtherSOCIAL SECURITY