Provider Demographics
NPI:1194062083
Name:MIMS, MATTHEW LEE (COTA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:MIMS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 LEAFLET LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77388-5961
Mailing Address - Country:US
Mailing Address - Phone:214-422-3631
Mailing Address - Fax:
Practice Address - Street 1:603 LEAFLET LN
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77388-5961
Practice Address - Country:US
Practice Address - Phone:214-422-3631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210118224Z00000X
NM2974224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant