Provider Demographics
NPI:1295211167
Name:BUMP CANCER, CORP
Entity Type:Organization
Organization Name:BUMP CANCER, CORP
Other - Org Name:BUMP CANCER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:WYLLIE
Authorized Official - Middle Name:V
Authorized Official - Last Name:MCGRUDER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC, MS
Authorized Official - Phone:706-358-7958
Mailing Address - Street 1:233 12TH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2462
Mailing Address - Country:US
Mailing Address - Phone:706-358-7958
Mailing Address - Fax:
Practice Address - Street 1:233 12TH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2462
Practice Address - Country:US
Practice Address - Phone:706-358-7958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010144101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty