Provider Demographics
NPI:1518576115
Name:MIMES, KEISHA DESHEA
Entity Type:Individual
Prefix:
First Name:KEISHA
Middle Name:DESHEA
Last Name:MIMES
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 1:368 OXFORD CIR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8263
Mailing Address - Country:US
Mailing Address - Phone:606-733-5299
Mailing Address - Fax:
Practice Address - Street 1:181 OLD WHITLEY RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8211
Practice Address - Country:US
Practice Address - Phone:606-330-0223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY264348225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY264348OtherKY STATE LICENSE