Provider Demographics
NPI:1487248597
Name:MIXON, MALORI BETH
Entity type:Individual
Prefix:
First Name:MALORI
Middle Name:BETH
Last Name:MIXON
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 1:948 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3425
Mailing Address - Country:US
Mailing Address - Phone:918-649-7989
Mailing Address - Fax:
Practice Address - Street 1:144 W RUTH AVE
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-4002
Practice Address - Country:US
Practice Address - Phone:918-649-7989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101YM0800X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator