=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043513419
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEHNIDE MUATA LUMUMBA CSAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2010
-----------------------------------------------------
Last Update Date | 12/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3020 W VLIET ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53208-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-312-8910
-----------------------------------------------------
Fax | 414-455-3292
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3020 W VLIET ST
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53208-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-312-8910
-----------------------------------------------------
Fax | 414-455-3292
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 15253-132
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------