Provider Demographics
NPI:1801925417
Name:MIX, SUSAN GAIL (COUNSELING INTERN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:GAIL
Last Name:MIX
Suffix:
Gender:F
Credentials:COUNSELING INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4457
Mailing Address - Country:US
Mailing Address - Phone:253-502-2696
Mailing Address - Fax:253-502-2757
Practice Address - Street 1:1323 YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4457
Practice Address - Country:US
Practice Address - Phone:253-502-2696
Practice Address - Fax:253-502-2757
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARC00023513101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARC00023513OtherREGISTERED COUNSELOR