Provider Demographics
NPI:1518928324
Name:MIMM, GREGORY STEWART (MFT 25700 CALIFORNIA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:STEWART
Last Name:MIMM
Suffix:
Gender:M
Credentials:MFT 25700 CALIFORNIA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 DOVE
Mailing Address - Street 2:#285
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2843
Mailing Address - Country:US
Mailing Address - Phone:949-261-5765
Mailing Address - Fax:
Practice Address - Street 1:1151 DOVE
Practice Address - Street 2:#285
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2843
Practice Address - Country:US
Practice Address - Phone:949-261-5765
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT25700106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist