Provider Demographics
NPI:1407689631
Name:MIMMS, KATJA AISHA (LCPC)
Entity type:Individual
Prefix:
First Name:KATJA
Middle Name:AISHA
Last Name:MIMMS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 E 45TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 E RANDOLPH ST FL 4
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-5099
Practice Address - Country:US
Practice Address - Phone:312-653-7645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-22
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.011266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional