Provider Demographics
NPI:1982879300
Name:MIMS, ALEXIS
Entity Type:Individual
Prefix:MR
First Name:ALEXIS
Middle Name:
Last Name:MIMS
Suffix:
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 1:1447 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2715
Mailing Address - Country:US
Mailing Address - Phone:424-757-7783
Mailing Address - Fax:
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 1802
Practice Address - City:CENTURY CITY
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-553-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-27
Last Update Date:2008-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)