Provider Demographics
NPI:1023155207
Name:MIMS, STALEY WOOD III (QMHP MED)
Entity type:Individual
Prefix:
First Name:STALEY
Middle Name:WOOD
Last Name:MIMS
Suffix:III
Gender:M
Credentials:QMHP MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3602 SE 28TH PL APT 15
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-3070
Mailing Address - Country:US
Mailing Address - Phone:503-771-0968
Mailing Address - Fax:
Practice Address - Street 1:2330 NE SISKIYOU ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2471
Practice Address - Country:US
Practice Address - Phone:503-528-0757
Practice Address - Fax:503-528-0764
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered372600000XNursing Service Related ProvidersAdult Companion