Provider Demographics
NPI:1275884892
Name:MIMS, SALLY ANN (BSW)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:ANN
Last Name:MIMS
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3393 HACKETT RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-9614
Mailing Address - Country:US
Mailing Address - Phone:989-401-5585
Mailing Address - Fax:989-401-5585
Practice Address - Street 1:3400 S WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-4958
Practice Address - Country:US
Practice Address - Phone:989-755-1072
Practice Address - Fax:989-755-1401
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)