Provider Demographics
NPI:1437883170
Name:MUMICH, AUTUMN PAGE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:PAGE
Last Name:MUMICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 SOPHIA COXE DR
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:PA
Mailing Address - Zip Code:18224-3068
Mailing Address - Country:US
Mailing Address - Phone:570-710-2152
Mailing Address - Fax:
Practice Address - Street 1:351 TENNY ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-3264
Practice Address - Country:US
Practice Address - Phone:888-726-4774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-09
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2301569311Medicaid