Basic Information
| Provider Information | |||||||||
| NPI: | 1730313552 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUMMAW | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5671 N SKEEL AVE | ||||||||
| Address2: | |||||||||
| City: | OSCODA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487501535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897392550 | ||||||||
| FaxNumber: | 9893583750 | ||||||||
| Practice Location | |||||||||
| Address1: | 5671 N SKEEL AVE | ||||||||
| Address2: | |||||||||
| City: | OSCODA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487501535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897392550 | ||||||||
| FaxNumber: | 9893583750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2009 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 1224 | MT | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | 6401010130 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1477745370 | 05 | MT | MEDICAID |