Healthcare Provider Details

I. General information

NPI: 1770168668
Provider Name (Legal Business Name): PAYTON BROOKE MUMMAU MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 BUSTLETON AVE STE A
PHILADELPHIA PA
19115-3810
US

IV. Provider business mailing address

19750 S VERMONT AVE STE 140
TORRANCE CA
90502-1130
US

V. Phone/Fax

Practice location:
  • Phone: 856-346-0005
  • Fax:
Mailing address:
  • Phone: 310-324-1753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH006089
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: