Provider Demographics
NPI:1174755425
Name:MIMS, MELVIA D (DPT)
Entity type:Individual
Prefix:
First Name:MELVIA
Middle Name:D
Last Name:MIMS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1153 GULF BREEZE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-7807
Mailing Address - Country:US
Mailing Address - Phone:850-932-6382
Mailing Address - Fax:850-932-5215
Practice Address - Street 1:931 US HIGHWAY 331 S
Practice Address - Street 2:UNIT H
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32435-8720
Practice Address - Country:US
Practice Address - Phone:850-892-7644
Practice Address - Fax:850-892-0420
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT24928225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist