Healthcare Provider Details

I. General information

NPI: 1972930527
Provider Name (Legal Business Name): MS. CRYSTAL O'NEAL MIMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 GARRISON RD
BROOKLINE MA
02445-4445
US

IV. Provider business mailing address

168 POND ST
RANDOLPH MA
02368-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-277-8107
  • Fax:
Mailing address:
  • Phone: 617-594-4852
  • Fax: 617-965-5313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: