Provider Demographics
NPI:1801553680
Name:MCCUMBER, BRENDA LEE
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:LEE
Last Name:MCCUMBER
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 1:689 IRVING PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44054-1641
Mailing Address - Country:US
Mailing Address - Phone:216-201-0279
Mailing Address - Fax:
Practice Address - Street 1:689 IRVING PARK BLVD
Practice Address - Street 2:
Practice Address - City:SHEFFIELD LAKE
Practice Address - State:OH
Practice Address - Zip Code:44054-1641
Practice Address - Country:US
Practice Address - Phone:216-201-0279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRG221586172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver