Healthcare Provider Details

I. General information

NPI: 1063625432
Provider Name (Legal Business Name): MOCHA MARIE MIMS LCMHC, PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 VILLAGE CIRCLE WAY APT 513
DURHAM NC
27713-6133
US

IV. Provider business mailing address

100 VILLAGE CIRCLE WAY APT 513
DURHAM NC
27713-6133
US

V. Phone/Fax

Practice location:
  • Phone: 919-777-3100
  • Fax:
Mailing address:
  • Phone: 919-777-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009343
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number12665
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: