Provider Demographics
NPI:1134829500
Name:MIMS, ANGELA MYRISE
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MYRISE
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 1:14801 STANSBURY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-3249
Mailing Address - Country:US
Mailing Address - Phone:313-778-2627
Mailing Address - Fax:
Practice Address - Street 1:13929 HARPER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3672
Practice Address - Country:US
Practice Address - Phone:313-371-0055
Practice Address - Fax:313-371-1409
Is Sole Proprietor?:No
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI520067619065OtherDRIVER LICENSE