Provider Demographics
NPI:1508629825
Name:MUMFORD, AMBER R
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:R
Last Name:MUMFORD
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 1:3205 ELENA WAY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-7861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 WEATHERSTONE DR STE 530
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7006
Practice Address - Country:US
Practice Address - Phone:770-591-9552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty