| Doctor Name: | STALEY WOOD MIMS |
| NPI Number: | 1023155207 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | QMHP MED |
| License Number: | |
| Business Practice Address: | 2330 Ne Siskiyou St Portland, OR - 972122471 |
| Business Phone Number: | 5035280757 |
| Business Fax Number: | 5035280764 |
| Mailing Address: | 3602 Se 28th Pl Apt 15, PORTLAND |
| State: | OR |
| Postal Code: | 972023070 |
| Phone Number: | 5037710968 |
| Fax Number: | |
| NPI Enumeration Date: | 01/30/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 372600000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | X |
| State: | |
| Taxonomy Type: | Nursing Service Related Providers |
| Taxonomy Classification: | Adult Companion |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual who provides supervision, socialization, and non-medical care to a functionally impaired adult. Companions may assist or supervise the individual with such tasks as meal preparation, laundry and shopping, but do not perform these activities as discrete services. These services are provided in accordance with a therapeutic goal in the plan of care. |