Healthcare Provider Details

I. General information

NPI: 1639158249
Provider Name (Legal Business Name): MIMI W THEIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 11/28/2024
Certification Date: 11/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US DEPT OF STATE M/MED/QM SA-1
WASHINGTON DC
20522-2006
US

IV. Provider business mailing address

US DEPT OF STATE M/MED/QM SA-1
WASHINGTON DC
20522-0102
US

V. Phone/Fax

Practice location:
  • Phone: 617-680-4168
  • Fax:
Mailing address:
  • Phone: 617-680-4168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD045795
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD045795
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: