Provider Demographics
NPI:1073364964
Name:MIMS, ROGER JR
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
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 1:2104 BOULDER DR
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-1517
Mailing Address - Country:US
Mailing Address - Phone:810-662-2220
Mailing Address - Fax:
Practice Address - Street 1:2104 BOULDER DR
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1517
Practice Address - Country:US
Practice Address - Phone:810-662-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty