Provider Demographics
NPI:1003699836
Name:MIMS, DARRYL JAMES JR
Entity Type:Individual
Prefix:MR
First Name:DARRYL
Middle Name:JAMES
Last Name:MIMS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 OLD ENGLISH LN
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-7429
Mailing Address - Country:US
Mailing Address - Phone:973-494-4906
Mailing Address - Fax:
Practice Address - Street 1:941 S MCPHERSON CHURCH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5369
Practice Address - Country:US
Practice Address - Phone:910-286-4784
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-15
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician