Provider Demographics
NPI:1942047659
Name:MIXON, ALYSSA MICHELE
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MICHELE
Last Name:MIXON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:MICHELE
Other - Last Name:MYRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1002 RUMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3533
Mailing Address - Country:US
Mailing Address - Phone:307-395-7510
Mailing Address - Fax:307-395-7511
Practice Address - Street 1:1002 RUMSEY AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3533
Practice Address - Country:US
Practice Address - Phone:307-395-7510
Practice Address - Fax:307-395-7511
Is Sole Proprietor?:No
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician