Healthcare Provider Details

I. General information

NPI: 1164255006
Provider Name (Legal Business Name): PAMELA MIMS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4757 N 76TH ST
MILWAUKEE WI
53218-4732
US

IV. Provider business mailing address

4757 N 76TH ST
MILWAUKEE WI
53218-4732
US

V. Phone/Fax

Practice location:
  • Phone: 414-539-6999
  • Fax:
Mailing address:
  • Phone: 414-539-6999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number20319-130
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number20319-130
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: