Provider Demographics
NPI:1134681109
Name:MIMS, MALAKA (LICSW)
Entity Type:Individual
Prefix:
First Name:MALAKA
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3606
Mailing Address - Country:US
Mailing Address - Phone:508-239-4475
Mailing Address - Fax:
Practice Address - Street 1:83 MORSE ST STE 6
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-4350
Practice Address - Country:US
Practice Address - Phone:508-392-5525
Practice Address - Fax:508-213-3608
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-01
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1229341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical