Provider Demographics
NPI:1467036863
Name:MIMS, TARA IRIS (MS)
Entity Type:Individual
Prefix:MS
First Name:TARA
Middle Name:IRIS
Last Name:MIMS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 E 149TH ST RM 417
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-3907
Mailing Address - Country:US
Mailing Address - Phone:646-702-6965
Mailing Address - Fax:914-229-2022
Practice Address - Street 1:100 GIBSON BLVD
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-3376
Practice Address - Country:US
Practice Address - Phone:212-444-8881
Practice Address - Fax:914-229-2022
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst