Basic Information
| Provider Information | |||||||||
| NPI: | 1508182304 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIXON | ||||||||
| FirstName: | KANIECIA | ||||||||
| MiddleName: | LASHEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COOPER | ||||||||
| OtherFirstName: | KANIECIA | ||||||||
| OtherMiddleName: | LASHEA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.S., LMFT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5198 ARLINGTON AVE # 106 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925042603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517963621 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9500 HAVEN AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917305871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099806700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2010 | ||||||||
| LastUpdateDate: | 09/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF 63143 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | IMF 63143 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 94323 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.