Provider Demographics
NPI:1467618595
Name:MIMS, MELANIE
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 ASCALON CT
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30005-2526
Mailing Address - Country:US
Mailing Address - Phone:713-775-2272
Mailing Address - Fax:770-406-2629
Practice Address - Street 1:220 ASCALON CT
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30005-2526
Practice Address - Country:US
Practice Address - Phone:713-775-2272
Practice Address - Fax:770-406-2629
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SLP006845235Z00000X
TX18734235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP006845OtherSTATE LISENCE