Provider Demographics
NPI:1588870349
Name:WIXSON, SANDRA JEAN (PHD)
Entity type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:JEAN
Last Name:WIXSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 025331
Mailing Address - Street 2:SJO 14229
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33102
Mailing Address - Country:US
Mailing Address - Phone:512-757-1178
Mailing Address - Fax:
Practice Address - Street 1:ROTUNDA 8, CASA # 163
Practice Address - Street 2:ULLOA
Practice Address - City:ULLOA
Practice Address - State:HEREDIA
Practice Address - Zip Code:NA
Practice Address - Country:CR
Practice Address - Phone:115062-589-0526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23293103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00044PMedicare ID - Type UnspecifiedMEDICARE NUMBER