Basic Information
| Provider Information | |||||||||
| NPI: | 1437883170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUMICH | ||||||||
| FirstName: | AUTUMN | ||||||||
| MiddleName: | PAGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 SOPHIA COXE DR | ||||||||
| Address2: | |||||||||
| City: | FREELAND | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182243068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5707102152 | ||||||||
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| Practice Location | |||||||||
| Address1: | 351 TENNY ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178153264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887264774 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2022 | ||||||||
| LastUpdateDate: | 07/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 2301569311 | 05 | PA | MEDICAID |