Basic Information
| Provider Information | |||||||||
| NPI: | 1669619359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRUMMUND | ||||||||
| FirstName: | ANTONE | ||||||||
| MiddleName: | YOHANN | ||||||||
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| Credential: | MS, LISAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1743 SYCAMORE AVE | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864090927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3505 WESTERN AVE STE A | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864093074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9287578111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2009 | ||||||||
| LastUpdateDate: | 11/04/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LISAC-11438 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.