Provider Demographics
NPI:1306332416
Name:MIMS, COURTNEY DANIEL
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:DANIEL
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 1:469 SAN REMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-3099
Mailing Address - Country:US
Mailing Address - Phone:909-709-2253
Mailing Address - Fax:
Practice Address - Street 1:5425 PEACHTREE PKWY
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-6536
Practice Address - Country:US
Practice Address - Phone:855-850-0274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program