Provider Demographics
NPI:1881225027
Name:MIMS, TAQUILLA
Entity Type:Individual
Prefix:
First Name:TAQUILLA
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 1:17625 W 7 MILE RD UNIT 351271
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-7747
Mailing Address - Country:US
Mailing Address - Phone:313-802-1787
Mailing Address - Fax:313-668-6127
Practice Address - Street 1:29701 6 MILE RD STE 150A
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-8604
Practice Address - Country:US
Practice Address - Phone:313-802-1787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management