Basic Information
| Provider Information | |||||||||
| NPI: | 1730824145 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HIXON | ||||||||
| FirstName: | BRENDY | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430853192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148443800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1960 E COUNTY LINE RD | ||||||||
| Address2: | |||||||||
| City: | MINERAL RIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444409451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004092729 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2022 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/30/2022 | ||||||||
| NPIReactivationDate: | 06/22/2022 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 2615030 | 05 | OH | MEDICAID |