Healthcare Provider Details

I. General information

NPI: 1932667060
Provider Name (Legal Business Name): MUMA JOHN AZEH NCC, CCMHC, AND LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 STATE ST
CAYCE SC
29033-4342
US

IV. Provider business mailing address

29 BROKEN ARROW CT
BLYTHEWOOD SC
29016-8126
US

V. Phone/Fax

Practice location:
  • Phone: 803-939-0174
  • Fax: 803-753-5900
Mailing address:
  • Phone: 843-304-2958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7535
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number19959
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: