Provider Demographics
NPI:1083322853
Name:MUMFORD, TESSA
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:
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 1:90 HOWARD DR
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-8138
Mailing Address - Country:US
Mailing Address - Phone:502-633-1007
Mailing Address - Fax:
Practice Address - Street 1:261 RUCCIO WAY STE 190
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3566
Practice Address - Country:US
Practice Address - Phone:502-633-1007
Practice Address - Fax:502-805-1511
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYRBT-23-253489106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician