Provider Demographics
NPI:1194156927
Name:KUMM, SANDRA SUZANNE
Entity type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:SUZANNE
Last Name:KUMM
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 1:1857 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-1416
Mailing Address - Country:US
Mailing Address - Phone:734-776-2973
Mailing Address - Fax:
Practice Address - Street 1:194 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1620
Practice Address - Country:US
Practice Address - Phone:248-719-7671
Practice Address - Fax:248-719-7563
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015779103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily