Provider Demographics
NPI:1144991860
Name:MIMS, VICTORIA (LCPC)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:MIMS
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 1:17015 PINE CT
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1050
Mailing Address - Country:US
Mailing Address - Phone:708-203-9125
Mailing Address - Fax:
Practice Address - Street 1:20280 GOVERNORS HWY STE 105
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1068
Practice Address - Country:US
Practice Address - Phone:312-248-3481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006614101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional