Provider Demographics
NPI:1174984355
Name:MUMBY, SUSANNE (PSYD)
Entity type:Individual
Prefix:DR
First Name:SUSANNE
Middle Name:
Last Name:MUMBY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7034 S 44TH LN
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2215
Mailing Address - Country:US
Mailing Address - Phone:602-500-0274
Mailing Address - Fax:
Practice Address - Street 1:14780 W MOUNTAIN VIEW BLVD STE 110
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7280
Practice Address - Country:US
Practice Address - Phone:623-374-7774
Practice Address - Fax:855-959-1911
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 390200000X
AZ005166103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ555855Medicaid