Provider Demographics
NPI:1285758193
Name:MIXON, AMY ELIZABETH (LMT)
Entity type:Individual
Prefix:MS
First Name:AMY
Middle Name:ELIZABETH
Last Name:MIXON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 SE STEVENS RD
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-7560
Mailing Address - Country:US
Mailing Address - Phone:352-359-2910
Mailing Address - Fax:
Practice Address - Street 1:6519 SE MILWAUKIE AVE
Practice Address - Street 2:#202
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5519
Practice Address - Country:US
Practice Address - Phone:352-359-2910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-17
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA27626225700000X
OR18915225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist