Provider Demographics
NPI:1013162809
Name:MIMMS, TIFFANY ROSE (PHD)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:ROSE
Last Name:MIMMS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7324 SOUZA CIR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95831-4737
Mailing Address - Country:US
Mailing Address - Phone:916-216-8433
Mailing Address - Fax:
Practice Address - Street 1:1521 CORPORATE WAY
Practice Address - Street 2:STE 200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95831-3891
Practice Address - Country:US
Practice Address - Phone:916-216-8433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21784103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical