Provider Demographics
NPI:1730313552
Name:MUMMAW, MARY A (LCPC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:MUMMAW
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5671 N SKEEL AVE
Mailing Address - Street 2:
Mailing Address - City:OSCODA
Mailing Address - State:MI
Mailing Address - Zip Code:48750-1535
Mailing Address - Country:US
Mailing Address - Phone:989-739-2550
Mailing Address - Fax:989-358-3750
Practice Address - Street 1:5671 N SKEEL AVE
Practice Address - Street 2:
Practice Address - City:OSCODA
Practice Address - State:MI
Practice Address - Zip Code:48750-1535
Practice Address - Country:US
Practice Address - Phone:989-739-2550
Practice Address - Fax:989-358-3750
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1224101YM0800X
MI6401010130101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1477745370Medicaid