Provider Demographics
NPI:1912588096
Name:MIMS, THOMAS RAMEL IV
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RAMEL
Last Name:MIMS
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 MYERS RD
Mailing Address - Street 2:
Mailing Address - City:HOWES CAVE
Mailing Address - State:NY
Mailing Address - Zip Code:12092-2209
Mailing Address - Country:US
Mailing Address - Phone:518-231-5217
Mailing Address - Fax:
Practice Address - Street 1:625 MYERS RD
Practice Address - Street 2:
Practice Address - City:HOWES CAVE
Practice Address - State:NY
Practice Address - Zip Code:12092-2209
Practice Address - Country:US
Practice Address - Phone:518-231-5217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP105016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health