Healthcare Provider Details

I. General information

NPI: 1407554991
Provider Name (Legal Business Name): MIKAIL S LUMUMBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 12/23/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6001 WOODLAND AVE STE 703
CLEVELAND OH
44104-2775
US

IV. Provider business mailing address

17815 FAIRWAY DR APT 403
CLEVELAND OH
44135-1892
US

V. Phone/Fax

Practice location:
  • Phone: 216-466-6161
  • Fax:
Mailing address:
  • Phone: 216-466-6161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.189178
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: