Provider Demographics
NPI:1649821406
Name:MIMS, LIZA NICOLE (BCBA, MS)
Entity type:Individual
Prefix:
First Name:LIZA
Middle Name:NICOLE
Last Name:MIMS
Suffix:
Gender:F
Credentials:BCBA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7718 MCPHERSON RD STE 105
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-2816
Mailing Address - Country:US
Mailing Address - Phone:956-516-7009
Mailing Address - Fax:
Practice Address - Street 1:7718 MCPHERSON RD STE 105
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-2816
Practice Address - Country:US
Practice Address - Phone:956-516-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2704103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst