Provider Demographics
NPI:1770247967
Name:MIMS, LISA (SLP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 MONAHAN DR
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:TX
Mailing Address - Zip Code:76226-1365
Mailing Address - Country:US
Mailing Address - Phone:940-369-0553
Mailing Address - Fax:
Practice Address - Street 1:1212 LONG RD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76207-4232
Practice Address - Country:US
Practice Address - Phone:940-369-0553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19652235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist