Provider Demographics
NPI:1629514377
Name:MIMS, CHELSEY
Entity Type:Individual
Prefix:
First Name:CHELSEY
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 1:2973 HARBOR BLVD # 136
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17911 SKY PARK CIR
Practice Address - Street 2:STE E
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6322
Practice Address - Country:US
Practice Address - Phone:949-290-2276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician