Provider Demographics
NPI:1174989016
Name:MIMS, MARY
Entity type:Individual
Prefix:MISS
First Name:MARY
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:MIMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1051 185TH ST
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-3509
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1051 185TH ST
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-3509
Practice Address - Country:US
Practice Address - Phone:708-903-7689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490220741041C0700X
IN34006323A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical