Provider Demographics
NPI:1881777647
Name:MIMS, ROBERT WAYNE (PHD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:WAYNE
Last Name:MIMS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 CORONA DR
Mailing Address - Street 2:SUITE 256
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4320
Mailing Address - Country:US
Mailing Address - Phone:361-853-2511
Mailing Address - Fax:361-853-0074
Practice Address - Street 1:4646 CORONA DR
Practice Address - Street 2:SUITE 256
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4320
Practice Address - Country:US
Practice Address - Phone:361-853-2511
Practice Address - Fax:361-853-0074
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21944103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00QH70OtherBLUE CROSS/BLUE SHIELD