Provider Demographics
NPI:1639455348
Name:MIMS, GRETCHEN ANN (LMSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:GRETCHEN
Middle Name:ANN
Last Name:MIMS
Suffix:
Gender:F
Credentials:LMSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 BOLTON TRL
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514-9774
Mailing Address - Country:US
Mailing Address - Phone:585-889-6429
Mailing Address - Fax:
Practice Address - Street 1:81 BOLTON TRL
Practice Address - Street 2:
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514-9774
Practice Address - Country:US
Practice Address - Phone:585-889-6429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072120-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool