Provider Demographics
NPI:1366199465
Name:MIXON, THADEUS
Entity type:Individual
Prefix:
First Name:THADEUS
Middle Name:
Last Name:MIXON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:746 OYSTER POINT DR
Mailing Address - Street 2:
Mailing Address - City:REEDVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22539-3605
Mailing Address - Country:US
Mailing Address - Phone:607-377-2867
Mailing Address - Fax:
Practice Address - Street 1:2836 MARIGOLD AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-7624
Practice Address - Country:US
Practice Address - Phone:607-377-2867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist