Provider Demographics
NPI:1407554991
Name:LUMUMBA, MIKAIL S
Entity type:Individual
Prefix:
First Name:MIKAIL
Middle Name:S
Last Name:LUMUMBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17815 FAIRWAY DR APT 403
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-1892
Mailing Address - Country:US
Mailing Address - Phone:216-466-6161
Mailing Address - Fax:
Practice Address - Street 1:6001 WOODLAND AVE STE 703
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-2775
Practice Address - Country:US
Practice Address - Phone:216-466-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OHCDCA.189178101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist