Provider Demographics
NPI:1427802537
Name:MIMS, LOGAN (MA CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:LOGAN
Middle Name:
Last Name:MIMS
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9804
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27429-0804
Mailing Address - Country:US
Mailing Address - Phone:336-541-8167
Mailing Address - Fax:336-294-8091
Practice Address - Street 1:1305 W WENDOVER AVE STE C
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-8100
Practice Address - Country:US
Practice Address - Phone:336-541-8167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14947235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist