Provider Demographics
NPI:1528100872
Name:MIMS, RENNODIA R (TMLP)
Entity type:Individual
Prefix:
First Name:RENNODIA
Middle Name:R
Last Name:MIMS
Suffix:
Gender:F
Credentials:TMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:584 KENTUCKY AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695
Mailing Address - Country:US
Mailing Address - Phone:530-758-2160
Mailing Address - Fax:530-758-1386
Practice Address - Street 1:285 W COURT ST STE 207
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-2977
Practice Address - Country:US
Practice Address - Phone:530-758-2160
Practice Address - Fax:530-758-1386
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2017-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1049T103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical