Provider Demographics
NPI:1154807360
Name:WIXSON, LINDSEY
Entity type:Individual
Prefix:MS
First Name:LINDSEY
Middle Name:
Last Name:WIXSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15440 MYSTIC ROCK DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-8146
Mailing Address - Country:US
Mailing Address - Phone:847-636-1209
Mailing Address - Fax:
Practice Address - Street 1:15440 MYSTIC ROCK DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-8146
Practice Address - Country:US
Practice Address - Phone:847-636-1209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2260367103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool